Paediatric Hydrocephalus version 2.ppt

Paediatric Hydrocephalus Dr Govender Definition of Hydrocephalus Hydro means water Cephalus means head Occurs when there is a blockage in the circulation of CSF from spaces within the brain (ventricles) out over the surface of the brain and down the spinal cord When too much...

Paediatric Hydrocephalus Dr Govender Definition of Hydrocephalus Hydro means water Cephalus means head Occurs when there is a blockage in the circulation of CSF from spaces within the brain (ventricles) out over the surface of the brain and down the spinal cord When too much CSF gets trapped in the pathway, the ventricles expand and put pressure on the brain.  If hydrocephalus is severe and treatment is delayed “ A POINT OF NO RETURN WILL BE REACHED” HYDROCEPHALUS AS AN ISOLATED PHENOMENON REMAINS TREATABLE AS LONG AS THE CEREBRAL MANTLE DOES NOT FALL BELOW 1 CM Rosseau et al, J Neurosurg 77: 551-555,1992  Aetiology-Based Classification Primary Brain Malformation (Dysgenetic) Focal (Aqueductal Stenosis) Global (Holoprosencephaly) Secondary : Trauma Aneurysmal Subarachnoid Haemorrhage Infection Tumour  Classification A. COMMUNICATING NON COMMUNICATING B. INTRAVENTRICULAR OBSTRUCTIVE EXTRAVENTRICULAR OBSTRUCTIVE  Non-communicating hydrocephalus (the usual situation) is when there is a blockage in the flow of CSF. – In spina bifida the lower part of the brain goes further down the spinal cord than usual. This is called the Arnold Chiari Malformation. Some children with spina bifida develop hydrocephalus before birth, while others develop it when the back is closed surgically. – Other causes of non-communicating hydrocephalus include tumours or meningitis. Communicating hydrocephalus occurs when more CSF is produced than can be reabsorbed. It can also be as a result of meningitis or a traumatic brain injury  CSF CSF is a clear, colourless fluid that looks like water and is made up of water, salt, glucose and cells. It provides nutrients to the brain and spinal cord and takes away waste products. It also provides protection to the brain and spinal cord by acting as a shock absorber between the skull and the brain, and between the spinal cord and the bones around it (the spine). hour, and after moving around the brain it passes back into blood stream  CSF PRODUCTION AND ABSORPTION 50-80 % PRODUCED BY CHOROID PLEXUS ENERGY DEPENDENT PROCESS 20-50 % IS BY-PRODUCT OF CNS METABOLISM : ECF. BULK FLOW VIA EPENDYMA INTO THE VENTRICLES PRIMARY SITE OF ABSORPTION : SAGITTAL SINUS. PASSIVE PRESSURE GRADIENT OF 5-7 MM HG BETWEEN THE CSAS & SSS  Symptoms High pitched cry , Poor feeding Vomiting Large head Fontanelles (soft spots on the top of the head) being full and hard Headache Lethargy (sleeping more than usual, being difficult to wake up, not wanting to play as usual)  Signs Large head size or rapidly growing head where the circumference when plotted is crossing normal growth rates. The presence of full fontanelles ('soft spot') in a baby 'Sunset eyes' – where the white of the eye can be seen at the top of the eye and the cornea (coloured part of the eye) is low and partly covered by the lower eyelid. "Frontal Bossing" - the forehead more prominent.  Long term effects Children with spina bifida will have physical problems due to effects on the spinal cord. If they also have hydrocephalus they often have some learning problems and difficulty concentrating. Most are within the normal range of intelligence. Some can have vision problems, epilepsy, headaches and early onset of puberty. Many young people with spina bifida and hydrocephalus have completed university studies.  Fine motor skills – May have impaired dexterity affecting drawing and sports. – Handwriting can often be untidy Spatial awareness – Poor eye hand co ordination, poor sense of direction, unsure balance. Short term memory impairment – Difficulty following detailed sequence of instructions – Difficulties learning new information – Forgetting things they have learned – Difficulties with comprehension  Short attention span – May experience difficulty keeping to task. – They may not complete tasks, daydream and have difficulty following things when there is lots going on. Diminished motivation/initiation – May sit and wait for instructions. Often this is misinterpreted as laziness. Executive functions – Not thinking before acting, poor planning and organisation Inability to generalise – Difficulty transferring concepts from one situation to a different one, especially in mathematics. – Difficulty transferring problem solving experiences from one situation to another. Altered concept of time – No inclination to hurry.  Management Drainage Surgery Medication Third ventriculostomy  Blocked shunt Vomiting or loss of appetite Drowsiness Headache Complaining of headaches while sitting up that stop while lying down (postural headaches) Blurred vision Poor concentration and memory Changes in coordination of arms and legs Irritability Seizures (fits) Losing control of urine or faeces Also, in an infant, bulging fontanelle and increasing head size.