Clinical Case of Hydrocephalus PDF

Clinical CASE  A 30-year-old male presented with severe headaches for the last 3 days associated with episodic blurred and double vision with/without temporary vision loss.  The patient reported frequent headaches, incontinence of bowel and bladder, memory loss, prog...

Clinical CASE  A 30-year-old male presented with severe headaches for the last 3 days associated with episodic blurred and double vision with/without temporary vision loss.  The patient reported frequent headaches, incontinence of bowel and bladder, memory loss, progressive loss of other thinking or reasoning skills, difficulty walking (feet feeling "stuck“) and shuffling gait during the past year.  Papilledema and increased intraocular pressure were noticed on physical examination.  A lumbar puncture showed high CSF protein and pressure but no signs of infection.  Magnetic Resonance Imaging (MRI) of the brain showed obstructive hydrocephalus with a 1.5 cm mass in the pineal region.  Ventricular System of the Brain LO-1 The ventricles of the brain are four CSF-filled cavities located within the brain. These four CSF-filled cavities are: o Two lateral ventricles o Third ventricle o Fourth ventricle  Ventricular System of the Brain LO-1 1. Two Lateral ventricles (light blue) which are located in each cerebral hemispheres. They are connected with third ventricle (yellow) by two openings called ‘Interventricular foramen’ (dark blue). 2. Third ventricle is present in diencephalon connects with fourth ventricle (purple) through a duct called ‘Cerebral Aqueduct’ (red). 3. Fourth ventricle is present in hindbrain continues as small Central canal (green) in the spinal cord Ventricular System of the Brain LO-1  production of CSF by choroid plexuses LO-2 CSF is formed and secreted by Ependymal cells covering the blood vessels present in the Lateral, Third and Fourth ventricular cavities.  Absorption of CSF LO-2 In adult's total volume of CSF in all the spaces is about 150ml. The CSF is absorbed through arachnoid villi into dural venous sinuses.  Flow and absorption of cerebrospinal fluid (CSF) Lo-2 1. CSF from Lateral Ventricles goes to Third Ventricle through Interventricular Foramen then to the Fourth Ventricle through Cerebral Aqueduct then it passes to spinal cord through Central Canal 2. CSF from Fourth ventricle also flows through the openings and enters into Subarachnoid Space. Then it absorbs through the Arachnoid villi into the dural venous sinus. 3. Ultimately the venous blood drains into the Internal Jugular Vein which goes to Heart. Define hydrocephalus Lo-3  Abnormal increase in the volume of CSF  varieties of hydrocephalus LO-3  Noncommunicating Hydrocephalus Raised pressure of CSF is due to blockage at some point between its formation at the choroid plexus and its exit through the foramina in the roof of the fourth ventricle  Communicating Hydrocephalus No obstruction to the flow of the CSF varieties of hydrocephalus LO-3  varieties of hydrocephalus LO-3 A. Congenital hydrocephalus: Babies may be born with hydrocephalus or develop the condition shortly after delivery. Such as inherited genetic abnormalities that block the flow of CSF B. Acquired hydrocephalus: Certain factors can increase the risk of developing hydrocephalus at any age, such as brain or spinal cord tumors and infections.  Causes of hydrocephalus LO-3  If associated with increased CSF pressure, It is due to one of the following: 1. abnormal increase in the formation 2. blockage of the circulation of fluid 3. decreased absorption  Rarely associated with normal CSF pressure in which compensatory hypoplasia and atrophy of brain substance takes place  Causes of hydrocephalus LO-3 Excessive formation Blockage of the circulation Diminished absorption of cerebrospinal fluid  Symptoms of hydrocephalus lo-3 Common symptoms in infants: Enlarged head Vomiting Irritability Seizures Common symptoms in adults: Headache Vomiting Dizziness Reduced consciousness  SIGNS of hydrocephalus in infants lo-3  The internal pressure results in the expansion of the brain and the calvaria as the sutures and calvaria are still not fused  Increased head circumference  Diagnosis LO-4  Ultrasound is often the first test to diagnose infants because it is relatively simple and low risk. When used during routine prenatal exams, may also detect hydrocephalus in the fetus  Magnetic resonance imaging (MRI) can determine if the ventricles have enlarged, assess the CSF flow, and provide information about the brain tissue surrounding the ventricles. MRI is usually the initial test used to diagnose adults  Computed tomography (CT) can show enlarged ventricles or obstruction. Ultrasound MRI CT  Diagnosis LO-4  Spinal tap (lumbar puncture) allows to estimate CSF pressure and analyze the fluid by inserting a needle in the lower back and removing and testing some of the fluid.  Intracranial pressure monitoring (ICP) uses a small pressure monitor inserted into the brain or ventricles to measure the pressure.  Treatment Lo-5  Hydrocephalus is treated with one of two surgical options: 1. A shunt (tube) is surgically inserted into the brain and connected to a flexible tube placed under the skin to drain the excess fluid into either the chest cavity or the abdomen so it can be absorbed by the body 2. Endoscopic Third Ventriculostomy (ETV) Improves the flow of CSF out of the brain. A tiny hole is made at the bottom of the third ventricle and the CSF is diverted there to relieve pressure.