Infants with hydrocephalus presents with complaints such as poor feeding, vomiting, reduced activity and irritability. Children and adults with hydrocephalus present with complaints such as slowing of higher brain functions, headaches in the morning, neck pain, vomiting specially in the morning, visual abnormality, drowsiness, difficulty in walking. In children there may be delayed growth and sexual maturation. Symptoms of normal pressure hydrocephalus (NPH) include gait disturbance, dementia, and inability to control urination [6].

• Poor Feeding

  feeding habits Projectile vomiting Seizures Sleepiness or lack of alertness Very noticeable scalp veins In older children, headaches and visual changes may be seen. [chp.edu]

  Symptoms may include: Vomiting Poor feeding Listlessness Irritability Constant downward gaze of the eyes Occasional seizures In older children and adults, the bones of the skull have closed. [medtronic.com]

  Infants present with symptoms such as poor feeding, vomiting, irritability, and reduced activity. [news-medical.net]

• Precocious Puberty

  Consequences of chronic hydrocephalus may include precocious puberty in girls, learning disorders (eg, difficulties with attention, information processing, and memory), loss of vision, and impaired executive function (eg, problems with conceptualizing [msdmanuals.com]

  Enlargement of the third ventricle can lead to precocious puberty and short stature. [lecturio.com]

  They may reach puberty earlier than the average child (see precocious puberty ). About one in four develops epilepsy. [en.wikipedia.org]

• Vomiting

  Early symptoms may also include: Eyes that appear to gaze downward Irritability Seizures Separated sutures Sleepiness Vomiting Symptoms that may occur in older children can include: Brief, shrill, high-pitched cry Changes in personality, memory, or the [nlm.nih.gov]

  We describe a 2-year-old boy with multilocular hydrocephalus caused by repeated shunt infection, presenting with fever and vomiting. Magnetic resonance images (MRI) showed extraventricular cysts and severe ventricular deformity. [ncbi.nlm.nih.gov]

• Nausea

  Clinical presentation A 20-year-old male with a history of tuberous sclerosis, X-linked intellectual disability, and epilepsy presented to the emergency department with two days of nausea, emesis, seizures, and two months of progressive proptosis. [ncbi.nlm.nih.gov]

  Large, growing head with a noticeably bulging fontanel (the soft spot on top of a newborn's head) Pressure in brain, leading to changes in heart rate or breathing Balance changes Cognitive decline Headache Inability to look upward with the eyes Nausea [uchicagomedicine.org]

  Potential complications from the shunts or surgery can include: Infection Shunt malfunction that results in under-drainage or over-drainage of the CSF Bleeding Other complications may include fever, nausea or vomiting, irritability, headache, redness [choa.org]

  Both forms cause elevated intracranial pressure (ICP), which leads to headache, nausea, and/or vomiting. [amboss.com]

  […] and vomiting In adults: Balance changes Cognitive dulling with progression to headache Lethargy Nausea and vomiting The situations in older children and adults described above are considered urgent and may require immediate intervention. [uchospitals.edu]

• Failure to Thrive

  This disease is characterized by hypokalemia, hypochloremia, and metabolic alkalosis that is often associated with failure to thrive and recurrent episodes of dehydration. The combination of BS and cholelithiasis in an infant is very rare. [ncbi.nlm.nih.gov]

  The latter manifests itself as failure to thrive and developmental delays. Other signs include: Rapid increase in head circumference or head circumference is in the 98th percentile for the age or greater. [patient.info]

  In extreme cases, a child might have " failure to thrive " and miss growth milestones. [kidshealth.org]

• Neck Pain

  CASE REPORT: A 58-year-old lady presented with neck pain and difficulty in walking and numbness of all 4 limbs of 1-year duration. Diagnostics with magnetic resonance imaging of the head and the cervical spine were done in the referring hospital. [ncbi.nlm.nih.gov]

  Toddlers, older children, and adults show decreased mental capacity and may experience headaches, neck pain, vision disturbances, drowsiness, and unstable balance. [news-medical.net]

  Symptoms in children and adults include the following: Slowing of mental capacity, cognitive deterioration Headaches (initially in the morning) Neck pain, suggesting tonsillar herniation Vomiting, more significant in the morning Blurred vision: A consequence [emedicine.com]

• Muscle Spasticity

  spasticity (spasm) Slow growth (child 0 to 5 years) Slow or restricted movement Vomiting The health care provider will examine the baby. [nlm.nih.gov]

  spasticity (spasm) Slow growth (child 0-5 years) Slow or restricted movement Vomiting When a health care provider taps fingertips on the skull, there may be abnormal sounds that indicated thinning and separation of skull bones. [web.archive.org]

  spasticity (spasm) Slow growth (child 0 to 5 years) Slow or restricted movement Vomiting Exams and Tests The health care provider will examine the baby. [mountsinai.org]

  It most often appears as stiffness, especially in the legs, caused by abnormal tensing of the muscles (spasticity). [ghr.nlm.nih.gov]

• Skeletal Dysplasia

  Hydrocephalus is also a frequent component of skeletal dysplasias and craniosynostosis syndromes in which there is a disparity between brain size and skull size. [neuropathology-web.org]

  Hb Bart's hydrops fetalis syndrome) 8,13 cause of alpha thalassemia relatively common cause in Southeast Asia fetal skeletal dysplasia(s) 10 fetal lymphovascular anomalies cystic hygroma 8 high output flow states vein of Galen aneurysmal malformation [radiopaedia.org]

  dysplasias Twinnning Twin to twin transfusion Severe anemia in the donor twin or high-output failure in the recipient Tumors Fetal sacrococcygeal teratoma, hemangiomas (Hepatic, Klippel-Trenaunay syndrome), fetal adrenal neuroblastoma, placental tumors [perinatology.com]

  dysplasias cystic hygromas and lymphatic obstruction fetal infections toxoplasma, rubella, cytomegalovirus, herpes virus, syphilis, and parvovirus are the common fetal infections. [intechopen.com]

• Blurred Vision

  This can cause a wide range of symptoms, including headache, blurred vision, sickness and difficulty walking. [cuh.nhs.uk]

  In older children and adults there is no head enlargement from hydrocephalus, but symptoms may include headache, nausea, vomiting and, sometimes, blurred vision. [medicinenet.com]

  vision Diplopia (double vision) Sunsetting of the eyes, problems with balance Poor coordination Drowsiness Elderly (Normal pressure hydrocephalus) Progressive mental impairment and dementia Problems with walking Impaired bladder control leading to urinary [neurosurgery.ucla.edu]

  Symptoms in older children may include: Awkward gait Balance problems Blurred vision Double vision Downward deviation of the eyes Drowsiness or lethargy Headache Incontinence Irritability Memory loss Nausea with or without vomiting Show More During your [ucsfbenioffchildrens.org]

• Diplopia

  […] feeding Vomiting Sleepiness Irritability Downward deviation of the eyes (also called "sunsetting") Seizures Children and adults Headache followed by vomiting Nausea Papilledema (swelling of the optic disk which is part of the optic nerve) Blurred vision Diplopia [neurosurgery.ucla.edu]

  Eye examination for diplopia and ophthalmoplegia from a stretch of the abducent or oculomotor nerve. Papilledema will be more evident in adults than children. [lecturio.com]

  Symptoms may include: Headache Vomiting and/or nausea Papilledema (swelling of the optic disk which is part of the optic nerve) Visual disturbances: blurred vision, diplopia (double vision), and sun setting of the eyes Difficulty with balance, poor coordination [aesculapusa.com]

• Incontinence

  Incontinence worsens as dementia progresses. [amboss.com]

  A child with congenital hydrocephalus may experience difficulty walking or with eye-hand coordination whereas an elderly person with hydrocephalus may experience incontinence. [hydrocephalus.ca]

  Incontinence and gait problems were more likely to improve than cognition. Sixteen (53%) of 30 patients achieved a good overall functional outcome, and incontinence was the only feature significantly associated with good outcome ( P .04). [jamanetwork.com]

  Urinary incontinence appears late in the illness, and is present in 50% of patients at time of treatment. [en.wikipedia.org]

• Headache

  This case shows the importance of awareness of the possibility of delayed hydrocephalus in a patient with severe headache. [ncbi.nlm.nih.gov]

  Symptoms of such a blockage include headache and vomiting. Surgeons may be able to help the shunt open without having to replace it. There may be other problems with the shunt, such as kinking, tube separation, or infection in the area of the shunt. [nlm.nih.gov]

  Chiari I Malformation Patients who complain of chronic headaches localized to the back of the head, or headaches that are made worse by coughing, sneezing or physical exertion may have a disorder called Chiari I Malformation. [brighamandwomens.org]

• Irritability

  She returned 3 months later with irritability, acute paraplegia, and respiratory distress. Magnetic resonance imaging (MRI) showed an intramedullary T8-T9 tumor with syringomyelia. [ncbi.nlm.nih.gov]

  Children present with headache, vomiting, lethargy, irritability, esotropia, or paralysis of upward gaze. Seizures may occur. [msdmanuals.com]

  […] ability to reason or think Changes in facial appearance and eye spacing Crossed eyes or uncontrolled eye movements Difficulty feeding Excessive sleepiness Headache Irritability, poor temper control Loss of bladder control (urinary incontinence) Loss [nlm.nih.gov]

• Lethargy

  Children present with headache, vomiting, lethargy, irritability, esotropia, or paralysis of upward gaze. Seizures may occur. [msdmanuals.com]

  Symptoms can include vomiting, lethargy, headache, enlarged head or even seizures. There is no cure, but treatment may provide long-term relief. Definition The term "hydrocephalus" is derived from two Greek words: hydro (water) and kephale (head). [medtronic.com]

  Toddlers and older children Among toddlers and older children, signs and symptoms may include: Physical signs and symptoms Headache Blurred or double vision Eyes fixed downward (sunsetting of eyes) Abnormal enlargement of a toddler's head Sleepiness or lethargy [mayoclinic.org]

• Papilledema

  CASE REPORT: A 3-year-old boy presented with macrocephaly, visual field constriction, and papilledema. Neuroimagings showed enlargement of the ventricles without any mass lesions. [ncbi.nlm.nih.gov]

  […] children and adults include the following: Slowing of mental capacity, cognitive deterioration Headaches (initially in the morning) Neck pain, suggesting tonsillar herniation Vomiting, more significant in the morning Blurred vision: A consequence of papilledema [emedicine.com]

  Overview Pathophysiology Clinical features Diagnosis Communicating hydrocephalus CSF production CSF absorption Typical findings of raised ICP Headache, nausea, and vomiting Papilledema 6th nerve palsy Abnormal gait Impaired consciousness Cushing triad [amboss.com]

  – When papilledema is present, it is always caused by elevated intracranial pressure, but not all patients with elevated ICP will have papilledema. [cancertherapyadvisor.com]

• Difficulty Concentrating

  concentrating Normal pressure hydrocephalus (NPH) This form of the condition usually begins slowly and is more common in adults over the age of 60. [healthline.com]

Examination in infants may reveal head circumference ≥98th percentile for age, disjunction of sutures, dilated scalp veins, tense fontanelle, setting-sun sign, and lower limb spasticity.

Papilledema, failure of upward gaze, unsteady gait, large head, sixth nerve palsy and Macewen sign may be observed in examination of children and adults. Patients with NPH may exhibit increased reflexes and Babinski response in one or both feet. Variable difficulty in walking, sucking and grasping reflexes in adults may occur [7].

Size of ventricles and other structures could be assessed by computed tomography scanning (CT). Malformations or tumors are detected by magnetic resonance imaging (MRI). Ultrasonography through anterior fontanelle in infants may diagnose subependymal and intraventricular hemorrhage. Skull radiography detects erosion of sella turcica or beaten copper cranium seen in craniosynostosis to confirm position. MRI cine measures CSF stroke volume in the cerebral aqueduct. Diffusion tensor imaging (DTI) detects microstructural changes in periventricular white matter.

CSF examination is recommended in suspected case of hydrocephalus after hemorrhage and meningitis. Electroencephalography is recommended in patients with seizures. If X-linked hydrocephalus is suspected, genetic testing and counseling is recommended [8].

A surgical shunt placement is the preferred therapeutic option. Ventriculoperitoneal shunt is the most common procedure.

Ventriculoatrial shunt, lumboperitoneal shunt (used for communicating hydrocephalus, CSF fistula, or pseudotumor cerebri), Torkildsen shunt (in acquired obstructive hydrocephalus) and ventriculopleural shunt are other possible procedures [9].

Hydrocephalus of rapid-onset needs immediate attention which is managed by ventricular tap in infants, open ventricular drainage in children and adults, lumbar puncture (LP) in posthemorrhagic and postmeningitic hydrocephalus or ventriculoperitoneal or ventriculoatrial shunt.

Alternatives to shunting include choroid plexectomy, opening of a stenosed aqueduct and endoscopic fenestration of the floor of the third ventricle (contraindication is communicating hydrocephalus). Medical treatment with acetazolamide or furosemide may be advised in premature infants with non–acute posthemorrhagic hydrocephalus for delaying surgical intervention [10].

Hydrocephalus requires regular and long term follow-up. There could be complications after treatment such as, infection and choking or collapse of shunt causing rise in CSF pressure in which additional surgeries are considered. Children with hydrocephalus have developmental defects of motor function, mental retardation, defective vision, and risk for epilepsy. Patients with epilepsy have poor prognosis and are more likely to have an IQ lower than 90. About 60% of children with hydrocephalus attend the school and approximately 40% of children will lead normal lives [5].

Congenital hydrocephalus occurring in infants may be idiopathic, as a result of premature or obstructed delivery, a brain defect restricting the flow of cerebrospinal fluid, spina bifida, X-linked mutation, Dandy Walker malformation and arachnoid cysts the brain and spinal cord [2].

Acquired hydrocephalus occurs usually due to a blockage between the ventricles of the brain as a result of an injury or illnesses such as hemorrhage, meningitis, brain tumors, head injury, stroke in adults or children. In older people after brain injury, bleeding or infection, without any clear reason normal pressure hydrocephalus (NPH) may develop.

Approximately hydrocephalus accounts for 0.6 percent of all pediatric hospital admissions and three out of every thousand are born with hydrocephalus. The incidence of acquired hydrocephalus is not known. There is an equal incidence in both sexes with exceptions of X–linked disorders and normal pressure hydrocephalus. The disease shows two peaks one at infancy and other at adulthood on age curve. Adult cases account for 40% of total cases [3].

CSF is produced by the choroid plexus within brain ventricles at the rate of 0.20-0.35 ml/min and total volume in an adult is 120 ml. CSF flows from the lateral ventricle into the venous drainage through various foramina and ventricles in brain. The intracranial pressure increases if CSF is produced excessively or there is increased resistance to CSF flow, or there is increased venous sinus pressure.

First, temporal and frontal horns dilate asymmetrically resulting in elevation of the corpus callosum, followed by stretching of the septum pellucidum, thinning of the cerebral mantle, or enlargement of the third ventricle into the pituitary fossa which may result in pituitary dysfunction [4].

The mechanism of NPH is unclear and may be due to resistance to flow of resulting in intermittently elevation of CSF pressure, at night and ventricular enlargement is maintained despite normal pressure. This reflects increased force on the ventricular wall.

Hydrocephalus is not preventable. The risk could be minimized by regular antenatal check up and preventing premature labor. Posthemorrhagic and postmeningitic hydrocephalus could be prevented by avoiding head injuries and prompt treatment with antibiotics respectively.

Hydrocephalus is also termed as a hydrodynamic cerebrospinal fluid (CSF) disorder and is characterized by increase in volume of this fluid. If it progresses naturally without interventions, it leads to tonsillar herniation and compression of the brain stem which may cause respiratory arrest and death. This condition is diagnosed based on clinical findings, ophthalmic examination, CSF examination and CT scan of the head.

Such patients are treated with a shunt. Patients are reassessed for shunt revisions, complications and failure. In infants and children, hydrocephalus may cause poor development of cognitive function. It may cause loss of cognitive function in adults [1]. Persistent visual loss if occurs may persist even after treatment.

Definition

Hydrocephalus is a clinical condition characterized by disturbance of cerebrospinal fluid regulation (CSF) in the central nervous system ie. production, flow and absorption.

Cause

Hydrocephalus may be inborn without any cause or secondary to complications of delivery such as delay or obstruction, genetic disorders, spinal and brain malformations. 
In adults or children there is usually acquired hydrocephalus due to a blockage between the ventricles of the brain as a result of an injury or illnesses such as subarachnoid hemorrhage, venous thrombosis, meningitis, brain tumors, head injury or stroke.

Symptoms

Infants with hydrocephalus presents with complaints such as poor feeding, reduced activity, irritability, and vomiting. Children and adults presents with symptoms such as slowing of higher brain functions, headaches in the morning, neck pain, vomiting specially in the morning, blurred vision, double vision, difficulty in walking or drowsiness. 

Diagnosis

Hydrocephalus may be diagnosed on history and clinical examination along with investigations such as X-ray, CT, MRI, and USG. Other investigations such as CSF examination, electroencephalography, genetic screening may be advised if required based on the suspected cause.

Treatment

A surgical shunt placement is the preferred therapeutic option. Hydrocephalus with rapid-onset is an emergency which is managed by ventricular tap or drainage in infants and children or adults respectively. Lumbar puncture (LP) is treatment procedure for posthemorrhagic and postmeningitic hydrocephalus. Choroid plexectomy and opening of a stenosed aqueduct are alternatives to shunting, endoscopic fenestration of the floor of the third ventricle. Medical treatment with acetazolamide or furosemide may be advised in premature infants with non–acute posthemorrhagic hydrocephalus for delaying surgical intervention. 

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2. Hamilton MG. Treatment of hydrocephalus in adults. Semin Pediatr Neurol. Mar 2009;16(1):34-41.
3. Lacy M, Oliveira M, Austria E, Frim MD. Neurocognitive outcome after endoscopic third ventriculocisterostomy in patients with obstructive hydrocephalus. J Int Neuropsychol Soc. May 2009;15(3):394-8. 
4. Partington MD. Congenital hydrocephalus. Neurosurg Clin N Am. Oct 2001;12(4):737-42, ix
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