BIODATA OF THE PATIENT

Identification data
Name :Master Ashish
Age :7 months
Sex :male
C.R no :1040919
Bed no/ Wad : 6/Emergency Ward
Re!igion :Sikh
Nationa!it" :Indian
Date of admi##ion :$%/$$/$&
Diagno#i# :Hydrocehal!s "ith #SMM$
S!rgery %&ot done yet
Con#'!tant :'r(Singhi
Fat(e)# ed'cation : $lass 10
Fat(e)# occ'*ation :)ri*ate o"n +!siness
+ot(e# ed'cation : $lass ,
+ot(e)# occ'*ation :Ho!se"i-e
Adde## %.harad/ Mohali
Infomant :Mother
CHIEF CO+P,AINTS D-RIN. AD+ISSION
0he mother gi*es a history o- the child "ith congenital meningomyeloceal "hich kees on
enlarging/ so-t on the lo"er +ack( 0he child started crying e1cessi*ely and +eing irrita+le -or
a+o!t 2 to 6 days/ the child head is so-t and has +een increasing since 4 month "ith +!lging
-ontanelle
HISTOR/ OF PRESENT I,,NESS
$hild "as kno"n case o- #SMM$( Mother noticed the increased in head si3e since 4 months
old/ "hich "as rogressi*e in nat!re/ the child "as *ery irrita+le and cry e1cessi*ely( 0hey "ent
to a ri*ate doctor/ 0hen re-erred to )4I $handigarh -or -!rther management( 0he child "as
admitted once at 4months -or the #SMM$/ diagnosed as hydrocehal!s/ discharged and no"
admitted -or s!rgery(
HISTOR/ OF PAST I,,NESS
She has the no any e*idence o- ast disease +esides the #SMM$ and hydrocehal!s "hich
started at 4 months o- age
PERSONA, HISTOR/:0
Antenata! Hi#to": 0here "as no comlaints d!ring the ante natal eriod(
Bit( Hi#to": 'eli*ered on ,/5/5010 at 16 4M$H/ -!ll term &6'( At ,month 7S4 "as done /
detected as a case o- #SMM$(
De1e!o*menta! Hi#to": &o delay in any milestone( &ormal gro"th and de*eloment e1cet
"eakness in lo"er lim+s
Imm'ni2ation Hi#to": imm!ni3ed aroriate to age according to mother +!t no e*idence
FA+I,/ HISTOR/: N'c!ea fami!" 3it( 4 mem5e#

8ather90year Mother 57 year
4 years 6 months

In her -amily/ &o+ody has any e*idence o- disease s!ch as comm!nica+le :0(;(</ 4enetic
disorder/ hereditary disease :'(M(<
.ENERA, PH/SICA, E6A+INITION:0
;ody +!ilt % Weak
6ital signs % 0emerat!re= 9, c
% )!lse 190 ;)M
% >esiration 96 ;)M
Weight %10 kg
Height % 69 cm
?8$ % 49 cm
$hest circ!m-erence % 40 cm
Head shae % large head/ ?8$@ 49 cm/ +!lging -ontanelle
Eyes % s!nken eyes
#is % &ormal
&ose % &ormal/ no discharge
Ears % &o discharge/ &ormal shae
0eeth % nil
4!ms % )ink color
0ong!e % $oated/ "hitish color
&eck % #ymh nodes not ala+le/ no neck rigidity
0hyroid % &o a+normal gro"th
$hest % &ormal shae
A+domen % So-t/ normal shae/ normal so!nd
;ack % )resence o- #SMM$
4enitalia % $lean/ no discharge/ distended e1tremities
S/STE+IC ASSESS+ENT
4eneral Aearance % #ooks "eak
)ersonal hygiene % &ot "ell maintained
)ost!re % &ormal
&!tritional stat!s % )oor
$ongenital a+normality % &ot any
Anemia % &ot anemic
$yanosis % &o
8o!l +ody order % &o
8o!l +reath % &o
CARDIO7ASC-,AR S/STE+
&o history o- any cyanotic A acynotic congenital heart disease(
&o allor/ &o cyanosis/ &o edema(
Heart >ate % 190 ;)M BAicalC
$80 5 sec(
&ormal heart so!nd resent S1A S5(
RESPIRATOR/ S/STE+
>esiratory rate 96 ;)M
&o h/o 'ysnea
0rachea in &ormal osition
&o enlargement o- 0hyroid
&o edema in *oice=+o1
&ormal +reath so!nd
.ASTRO0INTESTINA, S/STE+
&o h/o 6omiting A Malena
h/o oor -eeding
A+dominal girth 96(2 cm(
;o"el so!nd resent in all -o!r D!adrants
&o organomegaly -o!nd
&o tenderness
,/+PHATIC S/STE+
&? #ymh node enlargement(
.ENTO-RINATOR/ S/STE+
&o any congenital disorder
&o h/o 70I
&o h/o incontinence/ 'ys!ria/ Haemat!ria
&o renal calc!li
&o h/o Hernia
Sel- *oiding/ 7/? is adeD!ate
Centa! Ne1o'# #"#tem:0
&o h/o o- sei3!res( &ormal >e-le1es(
Endocina! #"#tem:0
&o endocrinal dys-!nction is yet noticed(
&o disease related to endocrine system is resent(
NE-RO,O.ICA, ASSESS+ENT
Interaction "ith e1aminer % 8air
Interest in s!rro!nding % )oor
Acti*ity % )oor
Seech A artic!lation % $hild +a++les
Hearing % 4ood
6is!al % &ormal
6is!al -i1ation % #'n8en e"e#
?c!lar mo*ement % A+normal
+OTOR F-NCTION
)ost!re % &ormal
4ait % $o!ld not +e elicited
Ho % co!ld not +e elicite
M!scle mass % )oor/"eak
M!scle o"er % "eak/ secially lo"er lim+
M!scle coordination % &ot 4ood coordination
+-SC-,OS9ETA, S/STE+
&o any h/o m!sc!losketal disease(
&o any e*idence o- kyhosis/ #ordosis A scoliosis(
&o any congenital disorder s!ch as 0alies(
INTI.-+ENTAR/ S/SE+
&o h/o $yanosis
&o h/o allergy -rom any s!+stance/ o+Eect or medicine
&o h/o rash/ !tricaria or any other skin disease
Scal clean/ no dandr!--
&ail F no cl!++ing o- nails
Skin= &ormal t!rgor/ skin integrity maintained/ no ress!re sore/ no edema resent
Skin temerat!re@ 9, $
DISEASE AS PER ,ITREAT-RE
H/DROCEPHA,-S:
Hydrocehal!s is not a seci-ic diseaseG rather/ it reresents a di*erse gro! o- conditions
that res!lt -rom imaired circ!lation and a+sortion o- $S8 or/ in the rare circ!mstance/ -rom
increased rod!ction +y a choroid le1!s ailloma( H"doce*(a!'# also kno"n as H"ater on
the +rain/H is a medical condition in "hich there is an a+normal acc!m!lation o- cere+rosinal
-l!id :$S8< in the *entricles/ or ca*ities/ o- the +rain( 0his may ca!se increased intracranial
ress!re inside the sk!ll and rogressi*e enlargement o- the head/ con*!lsion/ and mental
disa+ility( Hydrocehal!s can also ca!se death( 0he name deri*es -rom the 4reek "ords :h!dro=<
H"aterH/ and :kehalos< HheadH(
DEFINITION% Hydrocehal!s can +e de-ined +roadly as a dist!r+ance o- -ormation/ -lo"/ or
a+sortion o- cere+rosinal -l!id :$S8< that leads to an increase in *ol!me occ!ied +y this -l!id
in the $&S(

0his condition also co!ld +e termed a hydrodynamic disorder o- $S8( Ac!te
hydrocehal!s occ!rs o*er days/ s!+ac!te hydrocehal!s occ!rs o*er "eeks/ and chronic
hydrocehal!s occ!rs o*er months or years(
Ac'te ("doce*(a!'# occ'# o1e da"#: #'5ac'te ("doce*(a!'# occ'# o1e 3ee8#: and
c(onic ("doce*(a!'# occ'# o1e mont(# o "ea#(
PH/SIO,O./:
0he $S8 is -ormed rimarily in the *entric!lar system +y the choroid le1!s/ "hich is sit!ated in
the lateral/ 9rd/ and 4th *entricles :mainly lateral and -o!rth<( Altho!gh most $S8 is rod!ced in
the lateral *entricles/ I52J originates -rom e1trachoroidal so!rces/ incl!ding the caillary
endotheli!m "ithin the +rain arenchyma( 0here is acti*e ne!rogenic control o- $S8 -ormation
as adrenergic and cholinergic ner*es inner*ate the choroid le1!s( Stim!lation o- the adrenergic
system diminishes $S8 rod!ction/ "hereas e1citation o- the cholinergic ner*es may do!+le the
normal $S8 rod!ction rate( &ormal $S8 rod!ction is 0(50=0(92 m#/minG In a normal child/
I50 m#/hr o- $S8 is rod!ced( 0he total *ol!me o- $S8 aro1imates 20 m# in an in-ant and
150 to 120 m# in an ad!lt( 0otal *ol!me o- $S8 in an ad!lt is 150 m#(
$S8 -lo" res!lts -rom the ress!re gradient that e1ists +et"een the *entric!lar system and
*eno!s channels( &ormally/ $S8 -lo"s -rom the lateral *entricles thro!gh the -oramina o- Monro
into the 9rd *entricle( It then tra*erses the narro" aD!ed!ct o- Syl*i!s/ "hich is I9 mm long and
5 mm in diameter in a child/ to enter the 4th *entricle( 0he $S8 e1its the 4th *entricle thro!gh
the aired lateral -oramina o- #!schka and the midline -oramen o- Magendie into the cisterns at
the +ase o- the +rain(
Hydrocehal!s res!lting -rom o+str!ction "ithin the *entric!lar system is called o5#t'cti1e or
noncomm'nicating ("doce*(a!'#. 0he $S8 circ!lates -rom the +asal cisterns osteriorly
thro!gh the cistern system and o*er the con*e1ities o- the cere+ral hemisheres( $S8 is a+sor+ed
rimarily +y the arachnoid *illi thro!gh tight E!nctions o- their endotheli!m +y the ress!re
-orces( $S8 is a+sor+ed to a m!ch lesser e1tent +y the lymhatic channels directed to the
aranasal sin!ses/ along ner*e root slee*es/ and +y the choroid le1!s itsel-( Hydrocehal!s
res!lting -rom o+literation o- the s!+arachnoid cisterns or mal-!nction o- the arachnoid *illi is
called nono5#t'cti1e or comm'nicating ("doce*(a!'#.
PATHOPHYSIOLOGY
Hydrocehal!s is !s!ally d!e to +lockage o- cere+rosinal -l!id :$S8< o!t-lo" in
the *entricles or in the s!+arachnoid sace o*er the +rain( In a erson "itho!t hydrocehal!s/
$S8 contin!o!sly circ!lates thro!gh the +rain/ its *entricles and the sinal cord and is
contin!o!sly drained a"ay into the circ!latory system( Alternati*ely/ the condition may res!lt
-rom an o*errod!ction o- the $S8 -l!id/ -rom a congenital mal-ormation +locking normal
drainage o- the -l!id/ or -rom comlications o- head inE!ries or in-ections(
$omression o- the +rain +y the acc!m!lating -l!id e*ent!ally may
ca!se con*!lsions and mental retardation( 0hese signs occ!r sooner in ad!lts/ "hose sk!lls no
longer are a+le to e1and to accommodate the increasing -l!id *ol!me "ithin( 8et!ses/ in-ants/
and yo!ng children "ith hydrocehal!s tyically ha*e an a+normally large head/ e1cl!ding the
-ace/ +eca!se the ress!re o- the -l!id ca!ses the indi*id!al sk!ll +ones K "hich ha*e yet to -!se
K to +!lge o!t"ard at their E!nct!re oints( 0he ele*ated intracranial ress!re may ca!se
comression o- the +rain/ leading to +rain damage and other comlications(
I- the -oramina o- the -o!rth *entricle or the cere+ral aD!ed!ct are +locked/ cereo+rosinal -l!id
:$S8< can acc!m!late "ithin the *entricles( 0his condition is called intena! ("doce*(a!'# and
it res!lts in increased $S8 ress!re( 0he rod!ction o- $S8 contin!es/ e*en "hen the assages
that normally allo" it to e1it the +rain are +locked( $onseD!ently/ -l!id +!ilds inside the +rain
ca!sing ress!re that comresses the ner*o!s tiss!e and dilates the *entricles( $omression o-
the ner*o!s tiss!e !s!ally res!lts in irre*ersi+le +rain damage( I- the sk!ll +ones are not
comletely ossi-ied "hen the hydrocehal!s occ!rs/ the ress!re may also se*erely enlarge the
head( 0he cere+ral aD!ed!ct may +e +locked at the time o- +irth or may +ecome +locked later in
li-e +eca!se o- a t!mor gro"ing in the +rainstem(
A s!+arachnoid hemorrhage may +lock the ret!rn o- $S8 to the circ!lation( I- $S8 acc!m!lates
in the s!+arachnoid sace/ the condition is called extena! ("doce*(a!'#( In this condition/
ress!re is alied to the +rain e1ternally/ comressing ne!ral tiss!es and ca!sing +rain damage(
0h!s res!lting in -!rther damage o- the +rain tiss!e and leading to necroti3ation(
T/PES OF H/DROCEPHA,-S
;ased on its !nderlying mechanisms/ hydrocehal!s can +e classi-ied
into comm'nicating and non0comm'nicating :o+str!cti*e<(
A: Comm'nicating ("doce*(a!'#/ also kno"n as non0o5#t'cti1e ("doce*(a!'#/ is ca!sed
+y imaired cere+rosinal -l!id resortion in the a+sence o- any $S8=-lo" o+str!ction +et"een
the *entricles and s!+arachnoid sace( It has +een theori3ed that this is d!e to -!nctional
imairment o- the arachnoid gran!lations/ "hich are located along the s!erior sagittal sin!s and
is the site o- cere+rosinal -l!id resortion +ack into the *eno!s system( 6ario!s ne!rologic
conditions may res!lt in comm!nicating hydrocehal!s/ incl!ding s!+arachnoid/intra*entric!lar
hemorrhage/ meningitis/ $hiari mal-ormation/ and congenital a+sence o- arachnoidal
gran!lations :Pacc(ioni;# gan'!ation#<( Scarring and -i+rosis o- the s!+arachnoid
sace -ollo"ing in-ectio!s/ in-lammatory/ or hemorrhagic e*ents can also re*ent resortion o-
$S8/ ca!sing di--!se *entric!lar dilatation(
Noma! *e##'e ("doce*(a!'# :&)H< is a artic!lar -orm o- comm'nicating
("doce*(a!'#/ characteri3ed +y enlarged cere+ral *entricles/ "ith only intermittently
ele*ated cere+rosinal -l!id ress!re( 0he diagnosis o- &)H can +e esta+lished only "ith the
hel o- contin!o!s intra*entric!lar ress!re recordings :o*er 54 ho!rs or e*en longer</ since
more o-ten than not instant meas!rements yield normal ress!re *al!es( 'ynamic comliance
st!dies may +e also hel-!l( Altered comliance :elasticity< o- the *entric!lar "alls/ as "ell
as increased *iscosity o- the cere+rosinal -l!id/ may lay a role in the athogenesis
o- noma! *e##'e ("doce*(a!'#(
Hydrocephalus ex vacuo also re-ers to an enlargement o- cere+ral *entricles and
s!+arachnoid saces/ and is !s!ally d!e to 5ain ato*(" :as it occ!rs in dementias</ ost=
tra!matic +rain inE!ries and e*en in some sychiatric disorders/ s!ch as schi3ohrenia( As
oosed to hydrocehal!s/ this is a com*en#ato" en!agement o- the $S8=saces in
resonse to 5ain *aenc("ma !o## = it i# not the res!lt o- increased $S8 ress!re(
B: Non0comm'nicating
&on=comm!nicating hydrocehal!s/ or o5#t'cti1e ("doce*(a!'#/ is ca!sed +y a $S8=-lo"
o+str!ction !ltimately re*enting $S8 -rom -lo"ing into the s!+arachnoid sace :either d!e to
e1ternal comression or intra*entric!lar mass lesions<(
Foamen of +ono o+str!ction may lead to dilation o- one or/ i- large eno!gh :e(g(/
in $olloid cyst</ +oth lateral *entricles(
T(e a<'ed'ct of S"!1i'#/ normally narro" to +egin "ith/ may +e o+str!cted +y a
n!m+er o- genetically or acD!ired lesions :e(g(/ atresia/ eendymitis/ hemorrhage/ t!mor< and
lead to dilation o- +oth lateral *entricles as "ell as the third *entricle(
Fo't( 1entic!e o+str!ction "ill lead to dilatation o- the aD!ed!ct as "ell as the lateral
and third *entricles(
T(e foamina of ,'#c(8a and foamen of +agendie may +e o+str!cted d!e to
congenital -ail!re o- oening
Bot( fom# can 5e eit(e congenita! o ac<'ied.
ETIO,O./
Hydrocehal!s can +e ca!sed +y imaired cere+rosinal -l!id :$S8< -lo"/ rea+sortion/ or
e1cessi*e $S8 rod!ction(
0he most common ca!se o- hydrocehal!s is $S8 -lo" o+str!ction/ hindering the -ree
assage o- cere+rosinal -l!id thro!gh the *entric!lar system and s!+arachnoid
sace :e(g(/stenosis o- the cere+ral aD!ed!ct or o+str!ction o- the inter*entric!lar
-oramina F foamina of +ono secondary
to t!mors/ hemorrhages/ in-ections or congenital mal-ormations<(
Hydrocehal!s can also +e ca!sed +y o*errod!ction o- cere+rosinal -l!id :relati*e
o+str!ction< :e(g(/ ailloma o- choroid le1!s<(
THE CA-SES INC,-DED THE FO,,OWIN.:
$ongenital ca!ses in in-ants and children
4
o ;rainstem mal-ormation ca!sing stenosis o- the aD!ed!ct o- Syl*i!s% 0his is
resonsi+le -or 10J o- all cases o- hydrocehal!s in ne"+orns(
o 'andy=Walker mal-ormation% 0his a--ects 5=4J o- ne"+orns "ith hydrocehal!s(
o Arnold=$hiari mal-ormation tye 1 and tye 5
o Agenesis o- the -oramen o- Monro
o $ongenital to1olasmosis
o ;ickers=Adams syndrome% 0his is an L=linked hydrocehal!s acco!nting -or 7J
o- cases in males( It is characteri3ed +y stenosis o- the aD!ed!ct o- Syl*i!s/
se*ere mental retardation/ and in 20J +y an add!ction=-le1ion de-ormity o- the
th!m+(
AcD!ired ca!ses in in-ants and children
o Mass lesions% Mass lesions acco!nt -or 50J o- all cases o- hydrocehal!s in
children( 0hese are !s!ally t!mors :eg/ med!llo+lastoma/ astrocytoma</ +!t cysts/
a+scesses/ or hematoma also can +e the ca!se(
6
o Hemorrhage% Intra*entric!lar hemorrhage can +e related to remat!rity/ head
inE!ry/ or r!t!re o- a *asc!lar mal-ormation(
o In-ections% Meningitis :esecially +acterial< and/ in some geograhic
areas/ cysticercosis can ca!se hydrocehal!s(
o Increased *eno!s sin!s ress!re% 0his can +e related to achondrolasia/ some
craniostenoses/ or *eno!s throm+osis(
o Iatrogenic% Hyer*itaminosis A/ +y increasing secretion o- $S8 or +y increasing
ermea+ility o- the +lood=+rain +arrier/ can lead to hydrocehal!s( As a ca*eat/
hyer*itaminosis A is a more common ca!se o- idioathic intracranial
hyertension/ a disorder "ith increased $S8 ress!re +!t small rather than large
*entricles(
o Idioathic
C,INICA, FEAT-RES
0he clinical resentation o- hydrocehal!s is *aria+le and deends on many -actors/ incl!ding
the age at onset/ the nat!re o- the lesion ca!sing o+str!ction/ and the d!ration and rate o- increase
o- the intracranial ress!re :I$)<( May +e raid/ slo" and steadily ad*ancing/ or intermittent(
In-ants
E1cessi*e head gro"th :may +e seen ! to age 9<(
'elayed clos!re o- the anterior -ontanelle(
8ontanelle tense and ele*ated a+o*e the s!r-ace o- the sk!ll(
Signs o- increased intracranial ress!re :I$)<
Alteration o- m!scle tone o- the e1tremities/ incl!ding clon!s or sasticity(
#ater hysical signs%
o 8orehead +ecomes rominent
o Scal aears shiny "ith rominent scal *eins(
o Eye+ro"s and eyelids may +e dra"n !"ard/ e1osing the sclera a+o*e the iris(
o In-ant cannot ga3e !"ard/ ca!sing s!nset eyes
o Stra+ism!s/ nystagm!s/ and otic atrohy may occ!r(
o In-ant has di--ic!lty holding head !(
o $hild may e1erience hysical or mental de*elomental lag(
Signs and Symtoms o- Increased I$) in In-ants and $hildren
6omiting
>estlessness and irrita+ility
High=itched/ shrill cry :in-ants<
>aid increase in head circ!m-erence :in-ants<
0ense/ +!lging -ontanelle :in-ants<
$hanges in *ital signs%
o Increased systolic +lood ress!re
o 'ecreased !lse
o 'ecreased and irreg!lar resirations
o Increased temerat!re
)!illary changes
)ailledema
)ossi+le sei3!res
#ethargy/ st!or/ coma
?lder children may also e1erience%
o Headache/ esecially on a"akening
o #ethargy/ -atig!e/ aathy
o )ersonality changes
o Searation o- cranial s!t!res :may +e seen in children ! to age 10<
o 6is!al changes s!ch as do!+le *ision
?lder $hildren
?lder children ha*e closed s!t!res and resent "ith signs o- I$$)
C,INICA, FEAT-RES IN THE PATIENT
Acc!eated ate of en!agement of t(e (ead
Anteio fontane! i# 3ide o*en: 5'!ging: #ca!* 1ein ae di!ated
sasticity/ clon!s :artic!larly in the lo"er e1tremities<
Sign# of IICP: e#t!e##ne##:iita5i!it": (ig( *itc(ed : #(i!! c"
)resent o- Setting s!n sign= in this/ the eyes are do"n t!rned "ith the sclera *isi+le
a+o*e the iris A !"ard ga3e is not ossi+le(
8orehead +ecomes rominent:+ossing<
'i--ic!lty in holding head !
May ha*e delayed hysical or mental de*eloment
)oor aetite/di--ic!lty in -eeding
)resence o- #SMM$

IN7ESTI.ATIONS/ DIA.NOSTIC ST-DIES
,a5oato" St'die#
&o seci-ic +lood tests are recommended in the "ork! -or hydrocehal!s(
4enetic testing and co!nseling might +e recommended "hen L=linked hydrocehal!s is
s!sected(
E*al!ate cere+rosinal -l!id :$S8< in osthemorrhagic and ostmeningitic hydrocehal!s
-or rotein concentration and to e1cl!de resid!al in-ection(
Imaging St'die#
$0 can assess the si3e o- *entricles and other str!ct!res(
M>I can e*al!ate -or $hiari mal-ormation or cere+ellar or eriaD!ed!ctal t!mors( It
a--ords +etter imaging o- the osterior -ossa than $0( M>I can di--erentiate normal
ress!re hydrocehal!s :&)H< -rom cere+ral atrohy altho!gh the distinctions may +e
challenging( 8lo" *oids in the third *entricle and transeendymal -l!id e1!dates are
hel-!l( Ho"e*er/ n!mero!s s!ita+le atients ha*e a +rain attern s!ggesti*e o- atrohy
and small *essel ischemic disease that may !ltimately +e &)H(
,
4!idelines -or imaging
st!dies in s!sected &)H ha*e +een esta+lished(
9
$0/M>I criteria -or ac!te hydrocehal!s incl!de the -ollo"ing%
o Si3e o- +oth temoral horns is greater than 5 mm/ clearly *isi+le( In the a+sence
o- hydrocehal!s/ the temoral horns sho!ld +e +arely *isi+le(
o >atio o- the largest "idth o- the -rontal horns to ma1imal +iarietal diameter :ie/
E*ans ratio< is greater than 90J in hydrocehal!s(
o 0ranseendymal e1!date is translated on images as eri*entric!lar
hyoatten!ation :$0< or hyerintensity :M>I 05="eighted and -l!id=atten!ated
in*ersion reco*ery B8#AI>C seD!ences<(
o ;allooning o- -rontal horns o- lateral *entricles and third *entricle :ie/ HMickey
mo!seH *entricles< may indicate aD!ed!ctal o+str!ction(
o 7"ard +o"ing o- the cor!s callos!m on sagittal M>I s!ggests ac!te
hydrocehal!s(
$0/M>I criteria -or chronic hydrocehal!s incl!de the -ollo"ing%
o 0emoral horns may +e less rominent than in ac!te hydrocehal!s(
o 0hird *entricle may herniate into the sella t!rcica(
o Sella t!rcica may +e eroded(
o Macrocrania :ie/ occiito-rontal circ!m-erence M9,
th
ercentile< may +e resent(
o $or!s callos!m may +e atrohied :+est areciated on sagittal M>I<( In this
case/ arenchymal atrohy and e1=*ac!o :rather than tr!e< hydrocehal!s -rom a
ne!rodegenerati*e disease sho!ld +e considered(
7ltrasonograhy thro!gh the anterior -ontanelle in in-ants is !se-!l -or e*al!ating
s!+eendymal and intra*entric!lar hemorrhage and in -ollo"ing in-ants -or ossi+le
de*eloment o- rogressi*e hydrocehal!s(
>adion!clide cisternograhy can +e done in &)H to e*al!ate the rognosis "ith regard to
ossi+le sh!nting( I- a late scan :4,=75 h< sho"s ersistence o- *entric!lar acti*ity "ith a
*entric!lar to total intracranial acti*ity :6/0 ratio< greater than 95J/ the atient is more
likely to +ene-it -rom sh!nting(
10
;eca!se o- its oor sensiti*ity in redicting sh!nt
resonse "hen the 6/0 ration is less than 95J/ this test is no longer commonly !sed(
Sk!ll radiograhs may deict erosion o- sella t!rcica/ or H+eaten coer crani!mH :called
+y some a!thors H+eaten sil*er crani!mH<( 0he latter can also +e seen in craniosynostosis(
M>I cine is an M>I techniD!e to meas!re $S8 stroke *ol!me :S6< in the cere+ral
aD!ed!ct( $ine hase=contrast M>I meas!rements o- S6 in the cere+ral aD!ed!ct does
not aear to +e !se-!l in redicting resonse to sh!nting(
11
'i--!sion tensor imaging :'0I< is a no*el imaging techniD!e that detects di--erences in
-ractional anisotroy :8A< and mean di--!si*ity :M'< o- the +rain arenchyma
s!rro!nding the *entricles( Imairment o- 8A and M' thro!gh '0I allo"s the
recognition o- microstr!ct!ral changes in eri*entric!lar "hite matter region that may +e
too s!+tle on con*entional M>I(
95
Ot(e Te#t#
A-ter sh!nt insertion/ con-irm correct ositioning o- installed hard"are "ith a lain
radiograh(
EE4 i- sei3!re occ!rs
BOO9S PATIENTS RES-,TS
History No fami!" (i#to"
H/? enlarged head -or ast 1
month
Meas!rement o- ?8$ 4= cm
)erc!ssion o- the in-antNs sk!ll may rod!ce a
tyical cracked ot so!nd :Mace"enNs sign<(
PRESENT
S!+d!ral 0a 0o E1l!de S!+d!ral Haematoma 6 6
#!m+ar !nct!re L 1
74S ;/# dilated lateral
dilated/
9 *entricles mildly
dilated
#SMM$ "ith
Hydrocehal!s
L ray sk!ll% >adiological -inding= "idening o-
the -ontanalle A erosion o- the intracranial +one
L 1
$(0 (Scan Sho" non comm!nicating
hydrocehal!s/ "ith
o+str!ction at the le*el o-
aD!ed!ct o- syl*i!s
)ne!moencehalograhy L L
$S8 A&A#OSIS 1 1
M>I 1 1
;lood analysis 1 1
+ANA.E+ENT
.oa!:
0o achie*e eD!ili+ri!m +et"een rod!ction and a+sortion
Aceta3olamide decreases the rod!ction o- $S8
>eeated #)/*entric!lar ta to maintain normal ress!re
TREAT+ENT
+EDICA, TREAT+ENT:
Aceta2o!amide >Diamox?
&oncometiti*e re*ersi+le inhi+itor o- en3yme car+onic anhydrase/ "hich cataly3es the reaction
+et"een "ater and car+on dio1ide/ res!lting in rotons and car+onate( 0his contri+!tes to
decreasing $S8 secretion +y choroid le1!s(
'oses% 52 mg/kg/d )? tidG not to e1ceed 100 mg/kg/d
,oo* di'etic#
0hese agents increase e1cretion o- "ater +y inter-ering "ith the chloride=+inding cotransort
system/ "hich res!lts -rom inhi+ition o- rea+sortion o- sodi!m and chloride in the ascending
loo o- Henle and distal renal t!+!le(
F'o#emide >,a#ix?
Mechanisms roosed -or lo"ering I$) incl!de lo"ering cere+ral sodi!m !take/ a--ecting
"ater transort into astroglial cells +y inhi+iting cell!lar mem+rane cation=chloride !m/ and
decreasing $S8 rod!ction +y inhi+iting car+onic anhydrase( 7sed as adE!ncti*e theray "ith
A$P in temorary treatment o- osthemorrhagic hydrocehal!s in neonates(
'oses% 1 mg/kg/d I6
+EDiCINES: ecei1ed 5" *atient
S.R.No. +EDICINE DOSE RO-TE FRE@ENC/ RATIONA,E
1( Syr( )$M( 60 mg ?ral Q6H A&0I)O>E0I$ A
A&A#4ESI$
5( InE 0a1im 200mg I/6 ;' Anti+iotic 8or re*ent
the secondary in-ection(
9( InE( Amikacin 152mg I/6 ;' Anti+iotic 8or re*ent
the secondary in-ection(
S-R.ICA, TREAT+ENT:
Hydrocehal!s can +e treated thro!gh a *ariety o- s!rgical roced!res/ incl!ding direct oeration
on the lesion ca!sing the o+str!ction/ s!ch as a t!morG *entric!lostomy /intracranial sh!nts -or
selected cases o- noncomm!nicating hydrocehal!s to di*ert -l!id -rom the o+str!cted segment
o- the *entric!lar system to the s!+arachnoid saceG and e1tracranial sh!nts :most common< to
di*ert -l!id -rom the *entric!lar system to an e1tracranial comartment/ -reD!ently the
eritone!m or right atri!m(
E1tracranial Sh!nt )roced!res
7entic'!o*eitonea! >7P? #('nt
A *entric!loeritoneal sh!nt remo*es e1cessi*e cere+rosinal -l!id -rom the *entricles
and sh!nts it to the eritone!m( A one="ay *al*e is resent in the t!+ing +ehind the ear(
o 'i*erts $S8 -rom a lateral *entricle or the sinal s!+arachnoid sace to the
eritoneal ca*ity(
o A t!+e is assed -rom the lateral *entricle thro!gh an occiital +!rr hole
s!+c!taneo!sly thro!gh the osterior asect o- neck and arasinal region to the
eritoneal ca*ity thro!gh a small incision in the right lo"er D!adrant(
o A *entric!lar access de*ice is an imlanted reser*oir and catheter !sed -or
remat!re neonates less than 5/000 g in lie! o- a sh!nt( 0he catheter drains -l!id
-rom the *entricles into the reser*oir/ "hich can then +e emtied !sing asetic
techniD!e( When "eight e1ceeds 5/000 g/ a sh!nt !s!ally can +e laced(
7entic'!oatia! >7A? #('nt%
o A t!+e is assed -rom the dilated lateral *entricle thro!gh a +!rr hole in the
arietal region o- the sk!ll(
o It then is assed !nder the skin +ehind the ear and into a *ein do"n to a oint
"here it discharges into the right atri!m or s!erior *ena ca*a(
o A one="ay ress!re=sensiti*e *al*e "ill close to re*ent re-l!1 o- +lood into the
*entricle and oen as *entric!lar ress!re rises/ allo"ing -l!id to ass -rom the
*entricle into the +loodstream(
7entic'!o*!e'a! #('nt%
o 'i*erts $S8 to the le!ral ca*ity(
o Indicated "hen the 6) or 6A ro!te cannot +e !sed(
7entic!e0ga!! 5!adde #('nt%
o 'i*erts $S8 to the common +ile d!ct(
o 7sed "hen all other ro!tes are !na*aila+le(
+o#t #('nt# (a1e t(e fo!!o3ing com*onent#:
o 6entric!lar t!+ing(
o A one="ay or !nidirectional ress!re=sensiti*e -lo" *al*e(
o A !ming cham+er(
o 'istal t!+ing(
Pogamma5!e #('nt# ae a1ai!a5!e( 0hese can +e rogrammed to a certain -lo"
ress!re and ress!re settings can +e readE!sted +ased !on atient resonse( A magnetic
de*ice is !sed to adE!st the ress!re setting o- the sh!nt *al*e( 0he !se o- a
rogramma+le sh!nt eliminates the need -or m!ltile s!rgeries or hosital *isits to adE!st
sh!nt ress!re(
S('nt Com*!ication#
Altho!gh a sh!nt may -!nction "ell immediately a-ter insertion/ comlications may
arise in the -orm o- kinking/ searation/ or l!gging o- the sh!nt t!+ing( )ost oerati*e
artially sh!nt +lockage may occ!r +y +loced tiss!e dislodge d!ring s!rgical roced!re( 0he
most serio!s comlication is in-ection o- the sh!nt leading to *entric!litis A seticemia(
When the sh!nt +ecomes in-ected it is !s!ally remo*ed A massi*e anti+iotic theray is
gi*en( ;eca!se o- gro"th d!ring early childhood/ sh!nts m!st +e re*ised eriodically(
&eed -or sh!nt re*ision -reD!ently occ!rs +eca!se o- occl!sion/ in-ection/ or mal-!nction/
esecially in the -irst year o- li-e(
Sh!nt re*ision may +e necessary +eca!se o- gro"th o- the child( &e"er models/ ho"e*er/
incl!de coiled t!+ing to allo" the sh!nt to gro" "ith the child(
Sh!nt deendency -reD!ently occ!rs( 0he child raidly mani-ests symtoms o- increased
I$) i- the sh!nt does not -!nction otimally( ?nset may +e s!dden or insidio!s(
$hildren "ith 6A sh!nts may e1erience endocardial cont!sions and clotting/ leading to
+acterial endocarditis/ +acteremia/ and *entric!litis or throm+oem+olism and cor
!lmonale(
$hildren "ith 6A sh!nts reD!ire +iann!al or ann!al chest L=ray to check length o- t!+ing(
$hest L=ray is also done d!ring gro"th s!rts/ esecially d!ring !+erty( When t!+ing is
short or close to +eing o!t o- the right atri!m/ sh!nt relacement needs to +e sched!led(
TESTIN. SH-NT FOR PATENC/:0
$omressing o- the cham+er or reser*oir
)!m is comressed -irmly and D!ickly "ith -ore-ingers
Pogno#i#
)rognosis deends on early diagnosis and romt theray(
With imro*ed diagnostic and management techniD!es/ the rognosis is +ecoming
considera+ly +etter(
o Many children e1erience normal motor and intellect!al de*eloment(
o 0he se*erity o- ne!rologic de-icits is directly roortional to the inter*al +et"een
onset o- hydrocehal!s and the time o- diagnosis(
Hydrocehal!s d!e to meningitis might sontaneo!sly resol*e d!e to grad!al
disaearance o- adhesions(
Aro1imately t"o=thirds o- atients "ill die at an early age i- they do not recei*e
s!rgical treatment(
Com*!ication#
Sei3!res(
Herniation o- the +rain(
Sontaneo!s arrest d!e to nat!ral comensatory mechanisms/ ersistent increased I$)/
and +rain herniation(
'e*elomental delays(
'eression in adolescents is common(
PATIENT: #'ge" not done "et: 5't accoding to docto: t(e" 3i!! *!an fo 10* #('nt afte
#(ifting to t(e 3ad
N-RSIN. +ANA.E+ENT
&!rsing Assessment
In-ants
Assess head circ!m-erence(
o Meas!re at the occiito-rontal circ!m-erence oint o- largest meas!rement(
o Meas!re the head at aro1imately the same time each day(
o 7se a centimeter meas!re -or greatest acc!racy(
)alate -ontanelle -or tenseness/ +!lging(
Assess !illary resonse(
Assess le*el o- conscio!sness :#?$<(
E*al!ate +reathing atterns and e--ecti*eness(
Assess -eeding atterns and atterns o- emesis(
Assess motor -!nction/ gait/ coordination(
'etermine attainment o- de*elomental milestones(
?lder $hildren
Meas!re *ital signs -or signs o- increased I$)(
Assess atterns o- headache/ emesis(
'etermine !illary resonse(
E*al!ate #?$(
Assess motor -!nction(
E*al!ate attainment o- milestones/ school er-ormance(
?+tain arentsN reort o- recent +eha*ior(
PRE OPERATI7E:
Assessment "ith artic!lar attention to recognition o- II$)
Meas!re ?8$ reg!larly/ alate -ontanelle -or e*idence o- +!lging si3e and tension
>ecord and "atch care-!lly the +eha*ior o- in-ant as crying as straining as crying can
ca!sed I$$)
>eort changes in *ital signs
Maintain n!trition% -eed +a+y -reD!ently
$hanges osition -reD!ently to lesser chances o- de*eloment o- ress!re on scal/
s!ort +a+yRs head care-!lly "hile li-ting to re*ent tra!ma
)reare +a+y -or diagnostic roced!res
Ens!re In-ormed consent +y the arents
POST OPERATI7E
>ecord *ital signs e*ery 12 to 90 mins a-ter s!rgery
Monitor -or sign o- I$$) % "idened !lse ress!re/ slo" !lse/ change in +ody
temerat!re
Assess !illary resonse(
Assess le*el o- conscio!sness :#?$<(
I- 6) sh!nt is done/ check eritoneal catheter tract -or s"elling / tenderness/ erythema
I- sign o- I$$)/ check atency o- the sh!nt +y comressing the reser*oir
I- di--ic!lt to deress/ noti-y the doctor
.ee the in-ant in the non oerati*e side to re*ent ress!re on sh!nt *al*e
.ee atient -lat a-ter 54 ho!rs o- s!rgery
I- -ontanelle is deressed/ in-ormed doctor
)ro*ide the medication as ordered
Ed!cate the arents on the -!nction o- the sh!nt and diagnostic roced!re/ care o- the
child a-ter discharge
N'#ing Diagno#e#
Ine--ecti*e $ere+ral 0iss!e )er-!sion related to increased I$) +e-ore s!rgery
Im+alanced &!trition% #ess 0han ;ody >eD!irements related to red!ced oral intake and
*omiting
>isk -or Imaired Skin Integrity related to alterations in #?$ and enlarged head
An1iety o- arents related to child !ndergoing s!rgery
>isk -or InE!ry related to mal-!nctioning sh!nt
>isk -or 'e-icient 8l!id 6ol!me related to $S8 drainage/ decreased intake
ostoerati*ely
>isk -or In-ection related to +acterial in-iltration o- the sh!nt
Ine--ecti*e 8amily $oing related to diagnosis and s!rgery
N-RSIN. DIA.NOSES IN THE PATIENT
8e*er related to disease condition(
High risk -or in-ection related to s!rgical "o!nd A in*asi*e line
&!trition alteration in less than +ody reD!irement(
.no"ledge de-icit regarding disease condition A health ro+lem
SHORT TER+ .OA,S
0o maintain +ody temerat!re/ and monitoring o- *ital signs
0o re*ent in-ection
0o maintain n!tritional le*el
0o ed!cate arents a+o!t the disease conditions
,ON. TER+ .OA,S
0o reha+ilitate the client
0o teach atient a+o!t the treatment regimen/ and -ollo" ! m
0o romote health
REFERENCES:
.liengman and et alG &elson 0e1t+ook o- )ediatricsG 1,
th
edition : E=;ook<
?) 4hai and et alG 4hai Essential )ediatricsG 7
th
EditionG ages 250=254
Issel+acher et alG HarrisonRs )rinciles o- Internal Medicine7th Edition :E=;ook<
'onna # WongG Essentials o- )ediatric &!rsingG 2
th
editionG )agesG1706=1709
Hocken+erry et al( WongRs &!rsing $are o- In-ants and $hildren( 7
th
Edition(
)agesG1706=1709(
)artha and et alG -!ndamentals o- )ediatricsG second editionG 671/717
#ioncot Mann!al o- n!rsing )ractice ,
th
editionGagesG 1497=1499(
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