SPECIAL NEEDS
Hydrocephalus


Definition

Hydrocephalus is an abnormal expansion of cavities (ventricles) within the brain that is caused by the accumulation of cerebrospinal fluid. Hydrocephalus comes from two Greek words: hydros means water and cephalus means head.
There are two main varieties of hydrocephalus: congenital and acquired. An obstruction of the cerebral aqueduct (aqueductal stenosis) is the most frequent cause of congenital hydrocephalus. Acquired hydrocephalus may result from spina bifida, intraventricular hemorrhage, meningitis, head trauma, tumors, and cysts.

Description

Hydrocephalus is the result of an imbalance between the formation and drainage of cerebrospinal fluid (CSF). Approximately 500 milliliters (about a pint) of CSF is formed within the brain each day, by epidermal cells in structures collectively called the choroid plexus. These cells line chambers called ventricles that are located within the brain. There are four ventricles in a human brain. Once formed, CSF usually circulates among all the ventricles before it is absorbed and returned to the circulatory system. The normal adult volume of circulating CSF is 150 ml. The CSF turn-over rate is more than three times per day. Because production is independent of absorption, reduced absorption causes CSF to accumulate within the ventricles.
There are three different types of hydrocephalus. In the most common variety, reduced absorption occurs when one or more passages connecting the ventricles become blocked. This prevents the movement of CSF to its drainage sites in the subarachnoid space just inside the skull. This type of hydrocephalus is called "noncommunicating." In a second type, a reduction in the absorption rate is caused by damage to the absorptive tissue. This variety is called "communicating hydrocephalus."
Both of these types lead to an elevation of the CSF pressure within the brain. This increased pressure pushes aside the soft tissues of the brain. This squeezes and distorts them. This process also results in damage to these tissues. In infants whose skull bones have not yet fused, the intracranial pressure is partly relieved by expansion of the skull, so that symptoms may not be as dramatic. Both types of elevated-pressure hydrocephalus may occur from infancy to adulthood.
A third type of hydrocephalus, called "normal pressure hydrocephalus," is marked by ventricle enlargement without an apparent increase in CSF pressure. This type affects mainly the elderly.
Hydrocephalus has a variety of causes including:
Hydrocephalus is believed to occur in approximately one to two of every 1,000 live births. The incidence of adult onset hydrocephalus is not known. There is no known way to prevent hydrocephalus.

Causes and symptoms

Hydrocephalus that is congenital (present at birth) is thought to be caused by a complex interaction of genetic and environmental factors. Aqueductal stenosis, an obstruction of the cerebral aqueduct, is the most frequent cause of congenital hydrocephalus. As of 2001, the genetic factors are not well understood. According to the British Association for Spina Bifida and Hydrocephalus, in very rare circumstances, hydrocephalus is due to hereditary factors, which might affect future generations.
Signs and symptoms of elevated-pressure hydrocephalus include:
Irritability is the most common sign of hydrocephalus in infants. If this is not treated, it may lead to lethargy. Bulging of the fontanelles, or the soft spots between the skull bones, may also be an early sign. When hydrocephalus occurs in infants, fusion of the skull bones is prevented. This leads to abnormal expansion of the skull.
Symptoms of normal pressure hydrocephalus include dementia, gait abnormalities, and incontinence (involuntary urination or bowel movements).

Diagnosis

Imaging studies”x ray, computed tomography scan (CT scan), ultrasound, and especially magnetic resonance imaging (MRI)”are used to assess the presence and location of obstructions, as well as changes in brain tissue that have occurred as a result of the hydrocephalus. Lumbar puncture (spinal tap) may be performed to aid in determining the cause when infection is suspected.

Treatment

The primary method of treatment for both elevated and normal pressure hydrocephalus is surgical installation of a shunt. A shunt is a tube connecting the ventricles of the brain to an alternative drainage site, usually the abdominal cavity. A shunt contains a one-way valve to prevent reverse flow of fluid. In some cases of non-communicating hydrocephalus, a direct connection can be made between one of the ventricles and the subarachnoid space, allowing drainage without a shunt.
Installation of a shunt requires lifelong monitoring by the recipient or family members for signs of recurring hydrocephalus due to obstruction or failure of the shunt. Other than monitoring, no other management activity is usually required.
Some drugs may postpone the need for surgery by inhibiting the production of CSF. These include acetazolamide and furosemide. Other drugs that are used to delay surgery include glycerol, digoxin, and isosorbide.
Some cases of elevated pressure hydrocephalus may be avoided by preventing or treating the infectious diseases which precede them. Prenatal diagnosis of congenital brain malformation is often possible, offering the option of family planning.

Prognosis

The prognosis for elevated-pressure hydrocephalus depends on a wide variety of factors, including the cause, age of onset, and the timing of surgery. Studies indicate that about half of all children who receive appropriate treatment and follow-up will develop IQs greater than 85. Those with hydrocephalus at birth do better than those with later onset due to meningitis. For individuals with normal pressure hydrocephalus, approximately half will benefit by the installation of a shunt.