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JonnMarie Justiniano

on 7 August 2013

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Transcript of Hydrocephalus

- Ultrasound
+ Uses high frequency sound waves to produce images
+ Often used for initial assessment for infants because it is relatively low risk
+ The machine is placed over the soft spot (fontanel) on top of the baby’s head.
+ Can also detect hydrocephalus prior to birth
- Research on ventriculostomy
+ Mostly used in Europe & somewhat in the US.
+ Discovering when should be used & risks & complications with surgery.
+ More attractive surgery because many of the complications associated with the shunt surgery are reduced or not even a factor.

- Creating a national registry to better track trends of hydrocephalus over time as well as quickly test hypotheses.

- Researching different placements of shunts to ensure they last as long as possible.
[2] National Institutes of Health. (2013, June 13). Hydrocephalus fact sheet. Retrieved from http://www.ninds.nih.gov/disorders/hydrocephalus/detail_hydrocephalus.htm

[3] Mayo Clinic. (2011, September 13). Hydrocephalus. Retrieved from http://www.mayoclinic.com/health/hydrocephalus/DS00393

[4] Hydrocephalus Association. (2013, August 1). Hydrocephalus. Retrieved from http://www.hydroassoc.org/

[5] Kestle, J. (2013, July 8). Hydrocephalus clinical research network. Retrieved from http://www.hcrn.org/

- Another study is dealing with hydrocephalus in premature children that have either a subgaleal reservoir or subgaleal shunt placed in order to lessen the accumulation of fluid.
+ 2 techniques are being compared to the placement of a permanent shunt system along with any associated complications.

- Using their registry to create a cohort of individuals to research how long an individual should be on antibiotics and which antibiotics work best.
Current Research
- Main goal: improve the lives of children with the disease.
+ Many agendas in the field of research concerning those with hydrocephalus.

- First goal: reduce the amount of infections with shunt surgery.
+ Worsened long term prognosis from ~ 8-10% of surgeries in the U.S. & Canada.
+ Ability to reduce overall hospital stay & the overall incidence of infection leading to a reduced morbidity rate.
Current Research
Treatment of acyclovir in 3 10 mg doses was given daily. This course of treatment began on the first day of life. Despite intensive care and respiratory support, the infant's clinical course rapidly deteriorated, and she died on the fourth day of life.

- NOT a preventable condition
> Prenatal care

> Protect against infectious illness

> Use appropriate safety equipment

> Always wear a seat belt
- Shunt systems
+ Mechanical malfunctions
+ Blockage
+ Infections

- Ventriculostomy
+ Intellectual impairment
+ Nerve damage
+ Physical disabilities
Complications of Surgery
Treatments and Drugs
Treatments and Drugs
- CT
+ Specialized X-ray technology that can produce cross-sectional views of the brain
+ Scanning is painless and takes about 20 mins
+ This test requires lying still, which means children usually require mild sedation
+ CT for hydrocephalus are usually used for emergency only

Brain Imaging
Brain Imaging
Brain Imaging
Brain Imaging
- The neurological exam depends on a person’s age

- Neurologist may ask questions and conduct relatively simple tests in order to determine
+ Reflexes
+ Muscle strength
+ Muscle tone
+ Sense of touch
+ Vision and eye movement
+ Hearing
+ Coordination
+ Balance
+ Mental status
+ Mood
Neurological Exam
- Headache

- Difficulty in remaining awake or waking up

- Loss of coordination or balance

- Loss of bladder control or a frequent urge to urinate

- Impaired vision

- Decline in memory, concentration and other thinking skills that may affect job performance
Symptoms in Middle-Aged Adults
If hydrocephalus has progressed by the time of birth, it may result in significant intellectual, developmental and physical disabilities
- Congenital hydrocephalus is present at birth due to:
+ Abnormal development of the CNS, obstructing the flow of CSF
+ Bleeding within the ventricles (premature birth)
+ Infection in the uterus during pregnancy, causing inflammation in the fetal brain tissues
> Rubella or Syphillis
Risk Factors
- Cushions the brain to prevent injury

- Removes waste products of the brain’s metabolism

- Flows back and forth between the brain cavity & spinal column to maintain a constant pressure within the brain

- Compensates for changes in blood pressure in the brain
What is CSF?
- Occurs in 1:500 to 1:1,000 babies.

- "Hydrocephalus" means water (hydro) in the head (cephalus).

- Congenital hydrocephalus is the most common
+ CSF is blocked because of the formation of the child's brain.

- Acquired hydrocephalus for other reasons:
+ Intraventricular hemorrhage 
+ Head injury
+ Brain infection
+ Brain tumor 
At birth, the infant weighed 4lbs and was 16in long. The Apgar score was 4 at 1 min and 5 at 5 minutes respectively. Endotracheal tube was placed at 7 minutes because of the infant's erratic respirations. Physical examination revealed hydrocephalus with a head circumference 36.5 cm, large anterior fontanel, diastasis of the sagittal suture. There was also decreased physical activity and diminished muscle tone. Tonic-clonic seizures began 6 hours after birth and were treated with phenytoin. Ultrasound examination confirmed bilateral ventriculomegaly.
- Hydrocephalus Association
- National Hydrocephalus Foundation
- Pediatric Hydrocephalus Foundation
For More Information
- Hydrocephalus Association
- Seattle Children’s Hospital
- The University of Washington
- The University of Utah
- Hydrocehpalus Clinical Research Network
- Hydrocephalus Research Guild
Current Research
- Fever
- Irritability
- Drowsiness
- Nausea
- Vomiting
- Headache
- Vision Problems
- Redness, Pain & Tenderness of the skin along the shunt path
- Recurrence of any initial Hydrocephalus symptoms
Signs & Symptoms of Surgical Problems
- Ventriculostomy
+ Small video camera (Endoscope) inside the brain
+ makes a hole in the bottom of one of the ventricles or between the ventricles
Treatments and Drugs
- Drainage system
+ Long flexible tube with a valve
+ One end of the tubing is usually placed in
one of the ventricles of the brain
+ The tubing is then tunneled under the skin to another
part of the body
Treatments and Drugs
Brain Imaging
+ Uses radio waves and a magnetic field to produce detailed 3-D or cross-sectional images of the brain
+ This test is painless, but is noisy and requires lying still
+ Some MRI scans can take up to an hour and may require sedation for children
+ Some hospitals may use a quick MRI scan which takes about 5 mins

Brain Imaging
Brain Imaging
- Brain imaging can show enlargement of the ventricles caused by excess CSF

- May also be used to identify underlying causes

- Can identify other conditions contributing to the symptoms

- Test may include
+ Ultrasound
+ Magnetic Resonance Imaging (MRI)
+ Computerized Tomography (CT)
Brain Imaging
- Loss of bladder control or a frequent urge to urinate

- Memory loss

- Progressive loss of other thinking or reasoning skills

- Difficulty walking, often described as a shuffling gait or the feeling of the feet being stuck

- Poor coordination or balance

- Slower than normal movements in general
Symptoms in Older Adults
- Change in personality
- Problems with attention
- Decline in school performance
- Poor appetite
- Seizures
- Sleepiness
- Difficulty remaining awake or waking up
- Abnormal enlargement of a toddler’s head
- Headache
- Nausea and vomiting
- Fever
- Delays in walking or talking
- Problems with previously acquired skills, such as walking and talking
- Blurred or double vision
- Unstable balance
- Poor coordination
- Irritability
Symptoms in Toddlers and Older Children
- Unusually large head
- Rapid increase in head size
- Bulging or tense soft spot on the top of the head
- Vomiting
- Sleepiness
- Irritability
- Poor feeding
- Seizures
- Eyes fixed downward
- Deficits in muscle tone and strength, responsiveness to touch and expected growth
Symptoms in Infants
- Lesions or tumors of the brain or spinal cord

- CNS infections
+ bacterial meningitis
+ mumps

- Bleeding in the brain from stroke or head injury

- Other traumatic brain injury
Other Contributing Factors
- Obstruction
+ Partial obstruction of the normal flow of CSF, either from one ventricle to another or from the ventricles to other spaces around the brain

- Poor Absorption
+ A problem with the mechanisms that enable the blood vessels to absorb CSF
+ Often related to inflammation of brain tissues from disease or injury

- Overproduction
+ The mechanisms for producing CSF create more than a normal amount and more than can be absorbed
Causes of Excess Fluid
- Hydrocephalus ex-vacuo
+ Usually occurs when a stroke or traumatic injury happens, the brain may actually shrink in size.

- Normal Pressure Hydrocephalus (NPH)
+ NPH is an increase in CSF due to a subarachnoid hemorrhage, head trauma, infection, tumor or complications of surgery
Types of Hydrocephalus
- Non-communicating hydrocephalus
+ Blockage in the ventricular pathway through which CSF flows

- Communicating hydrocephalus
+ Poor absorption of CSF when the pathways are not obstructed
Types of Hydrocephalus
- Cerebrospinal fluid (CSF) flows through the ventricles, brain, & spinal column.

- A buildup of fluid in the cavities of the brain.

- Fluid increases the size of the ventricles & pressure on the brain.

- Damages brain tissues and causes impairments in brain function.

- Most common in infants & older adults.
What is Hydrocephalus?
A female infant was delivered after 36 weeks of pregnancy. The 28 year old mother, who has been pregnant 3 times, but only had 1 live birth, was exposed to varicella zoster virus during week 17. Varicella infection was presented as chicken pox, but no antiviral treatment was given. Ultrasound examination 12 weeks later revealed abnormal fetal growth & enlarged ventricles in both sides of the brain.

Cyrena Choompoo
Jonn Marie Justiniano
Joanne Orquia
Melanie Santos
Anita Valentin

Treatments & Drugs
- 2 types of surgical treatments
+ Shunt
> VP shunt
> VA shunt
+ Ventriculostomy
What is CSF?
- Produced by the tissues lining the ventricles of the brain

- Flows through the ventricles by interconnecting channels and flows into the spaces around the brain & spinal column

- Absorbed primarily by blood vessels in tissues near the base of the brain

- Keeps the brain buoyant, allowing the brain to float within the skull
[6] Copstead, L. C., & Banasik, J. (2010). Pathophysiology. (4th ed., pp. 1073-1075, 1041-1042). Canada. Saunders Elsevier

[7] Marieb, E. (2004). Human anatomy & physiology. (6th Edition ed., pp. 464-466). New York, NY: Pearson Beanjamin Cummings.

[8] Ultrasound Image Gallery. (2013). Ultrasound images of fetal brain. Retrieved from http://www.ultrasound-images.com/fetal-brain.htm

[9] Seattle Children's Hospital Research Foundation. (2013). Hydrocephalus. Retrieved from http://www.seattlechildrens.org/medical-conditions/brain-nervous-system-mental-conditions/hydrocephalus/

[10] Upstate Medical University, N. (2007, July 30). Endoscopic third ventriculostomy. Retrieved from http://www.upstate.edu/practice/neurosurgery/education/med_students/3v/

[11] Ultrasoundpaedia. (2011). Ultrasound of the neonatal head - normal. Retrieved from http://www.ultrasoundpaedia.com/normal-neonatal-head/
Brain Imaging
Current Research
- General physical exam

- Neurological exam

- Brain imaging tests
Full transcript