Hydrocephalus

A comprehensive assessment of mental status, coordination, reflexes, and sensory function helps evaluate neurological impact and detect specific deficits.

For infants and young children, head circumference is tracked on growth charts. Abnormally rapid head growth can be an early sign of hydrocephalus in babies, as their unfused skull bones can expand with increased pressure.

A quick imaging method that provides clear images of the ventricles, identifying enlargement, obstruction, or other abnormalities. CT scans are particularly useful in emergency situations as they can be performed quickly and readily show ventricular size.

MRI provides detailed images of brain structure and CSF flow dynamics. This technique offers superior soft tissue contrast compared to CT scans and can better visualise the causes of obstruction such as tumours, cysts, or congenital malformations.

In infants with open fontanelles, ultrasound can be used to visualise the ventricles through the soft spots in the skull. This non-invasive technique is particularly valuable for monitoring ventricular size in premature babies at risk for intraventricular haemorrhage.

This procedure measures CSF pressure and allows analysis of fluid composition. In normal pressure hydrocephalus, a large-volume lumbar puncture may temporarily improve symptoms, which can be both diagnostic and predictive of shunt response.

In complex cases, a pressure sensor may be placed within the brain to record pressure changes over time. This continuous monitoring helps distinguish between true hydrocephalus and conditions that mimic it, particularly in cases where imaging findings are ambiguous.

Specialised MRI techniques visualise CSF flow patterns, identifying obstructions and guiding surgical planning.

• Medication: Diuretics such as acetazolamide or furosemide may temporarily reduce CSF production. These medications decrease fluid volume by inhibiting the production mechanisms in the choroid plexus but generally provide only short-term relief and are not definitive solutions for most cases.
• Serial Lumbar Punctures: For some patients, especially those with normal pressure hydrocephalus, removing CSF through regular lumbar punctures may temporarily alleviate symptoms. This approach may be used while awaiting surgery or in patients who cannot tolerate surgical interventions.
• Ventricular Tapping: In infants with rapidly enlarging ventricles, direct needle aspiration of CSF from the ventricles may provide temporary relief. This procedure is typically performed as a bridging measure before definitive surgical treatment.
• Observation: In cases of mild or compensated hydrocephalus, careful monitoring without immediate intervention may be appropriate. Regular imaging studies and neurological assessments track any progression and determine if active treatment becomes necessary.

• Ventriculoperitoneal (VP) Shunt: The most common surgical treatment involves placing a catheter in the ventricle connected to a valve and tubing that diverts excess CSF to the peritoneal cavity where it is absorbed. The valve regulates flow based on pressure differentials, preventing over-drainage.
• Endoscopic Third Ventriculostomy (ETV): This minimally invasive procedure creates an alternative pathway for CSF flow by making a small opening in the floor of the third ventricle. ETV is particularly effective for obstructive hydrocephalus and allows patients to avoid shunt-related complications, though success rates vary based on cause and patient age.
• Ventriculoatrial (VA) Shunt: Similar to a VP shunt, it diverts CSF to the right atrium of the heart through a catheter placed in the jugular vein. This approach may be used when the peritoneal cavity is unsuitable due to infection, adhesions, or previous abdominal surgeries.
• Ventriculopleural Shunt: In this less common variant, CSF is diverted to the pleural space around the lungs. This option may be considered when both peritoneal and atrial placements are contraindicated, though it carries risks of pleural effusion or respiratory compromise.
• Lumboperitoneal Shunt: Used primarily for communicating hydrocephalus, this shunt drains CSF from the lumbar subarachnoid space rather than directly from the ventricles. The system bypasses the ventricular system entirely, making it suitable for conditions like pseudotumour cerebri.
• Choroid Plexus Cauterisation: Sometimes combined with ETV, this procedure reduces CSF production by cauterising the choroid plexus tissue. This approach may improve outcomes in infants, particularly in regions with limited resources for shunt maintenance.