Hydrocephalus

R Dhaker, Asst. Professor, RCN 1

Introduction
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 Hydro Cephalus

water Head

Excessive accumulation of fluid in the brain

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 Definition
• Hydrocephalus is a
condition caused by an
imbalance in the
production and absorption
of CSF in the ventricular
system. When the
production is grater than
the absorption.
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Causes, incidence, and risk factors
Hydrocephalus may also be due to:
– Genetic defects

– Certain infections during pregnancy

In young children, hydrocephalus may result

from the following conditions:
– Infections that affect the central nervous system (such as
meningitis or encephalitis), especially in infants
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Cont…

– Bleeding in the brain during or soon after delivery

(especially in premature babies)

– Injury before, during, or after childbirth, including

subarachnoid hemorrhage

– Tumors of the central nervous system, including the

brain or spinal cord

– Injury or trauma

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 Classification
• Communicating

• non-communicating

• congenital or acquired

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 Signs and symptoms
Symptoms of hydrocephalus depend on:
– Age

– Amount of brain damage

– What is causing the build up of CSF fluid

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 Cont…

In infants with hydrocephalus, it causes the

fontanelle (soft spot) to bulge and the head to
be larger than expected. Early symptoms may
also include:
• Eyes that appear to gaze downward
• Irritability
• Seizures
• Separated sutures
• Sleepiness
• Vomiting
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Cont…

Symptoms that may occur in older children can

include:
– shrill, high-pitched cry
– Changes in personality, memory, or the ability to
reason or think
– Changes in facial appearance and eye spacing
– Crossed eyes or uncontrolled eye movements
– Difficulty feeding
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Cont…

– Excessive sleepiness
– Headache
– Irritability, poor temper control
– Loss of bladder control (urinary incontinence)
– Loss of coordination and trouble walking
– Muscle spasticity (spasm)
– Slow growth (child 0 - 5 years)
– Slow or restricted movement
– Vomiting
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RCN

19
 Diagnostic Evaluation
The doctor or nurse will examine the baby. This may show:
• Stretched or swollen veins on the baby's scalp
• Abnormal sounds when the health care provider taps lightly on the
skull, suggesting a problem with the skull bones
• All or part of the head may be larger than normal, usually in the front
part
• Eyes that look "sunken in"
• White part of the eye appears over the colored area, making it look like
a "setting sun"
• Reflexes may be normal
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Cont…

• A head CT scan is one of the best tests for

identifying hydrocephalus. Other tests that may be
done include:
– Arteriography
– Brain scan using radioisotopes
– Cranial ultrasound (an ultrasound of the brain)
– Lumbar puncture and examination of the cerebrospinal
fluid (rarely done)
– Skull x-rays
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 Treatment
• The goal of treatment is to reduce or prevent brain damage

by improving the flow of CSF.

• Options for treating hydrocephalus include:

– Shunt placement

– Third ventriculostomy
• combined endoscopic third ventriculostomy/choroid plexus

cauterization (ETV/CPC)
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 Medical management

• Then medical management is done to reduce

increased ICP by carbonic anhydrase inhibitor,
acetazolamide ( Diamox) 50 mg/ kg/ day to
reduce CSF production in slow progressive
hydrocephalus.

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 Shunt placement
• Most shunts drain the fluid into the
– peritoneal cavity (ventriculo-peritoneal shunt),

– Right atrium (ventriculo-atrial shunt),

– Pleural cavity (ventriculo-pleural shunt), and

– Gallbladder.

– Peritoneal cavity (Lumbar-peritoneal shunt).

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 Third ventriculostomy
• helped design and test the next generation of shunting
devices, including the externally programmable shunt
• introduced and refined the use of minimally invasive
surgical techniques—like the endoscopic third
ventriculostomy procedure (ETV), and the
landmark combined endoscopic third
ventriculostomy/choroid plexus cauterization
procedure (ETV/CPC)
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• The technique had largely been abandoned, until Warf began combining
it with endoscopic third ventriculostomy (ETV) and showed this
combined procedure was superior to ETV alone in infants.
During choroid plexus cauterization, the neurosurgeon:
– makes a small incision in the child’s scalp

– removes a tiny window of bone in the skull

– inserts a miniature tube called an endoscope outfitted with:

– an eye piece at the top attached to a video camera

– a wire passing through the endoscope that conducts precise electrical

charges

– two tiny light

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– a lens at the end of the tube

– advances the endoscope into the fluid spaces inside the brain
(the ventricles)

– performs the ETV by making an opening in the floor of the

third ventricle

– identifies the choroid plexus in the first and second ventricles

– turns on the electrical charge once the tube is in position,

cauterizing the choroid plexus in these two ventricles (but
preserving the choroid plexus in the third and fourth ventricles,
allowing continued production of cerebrospinal fluid)
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 Nursing Management:
• Teach the family about the management
required for the disorder
• Provide preoperative nursing care
• Provide Postoperative nursing care (nursing
interventions are the same as those for
increased ICP)
• Teach home care

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 Complications
• The shunt may become blocked
• Other complications may include:
– Complications of surgery
– Infections such as meningitis or encephalitis
– Intellectual impairment
– Nerve damage (decrease in movement, sensation,
function)
– Physical disabilities
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 Bibliography
• Marlow, text book of pediatric nursing, 6th edition , Saunders an
imprint of Elsevier , page no.- 1017-1022

• Wong’s, essential of pediatric nursing, 8th edition, Elsevier sector-16

Nodia, page no. –

• Parul data, pediatric Nursing, 2nd edition, jaypee brother medical

publisher(P) ltd. Mew delhi, page no.- 406-409
• http://www.childrenshospital.org/az/Site1116/mainpageS1116P4.html
• http://www.childrenshospital.org/az/Site1116/mainpageS1116P0.html
• http://www.childrenshospital.org/views/april11/new_hope_for_infants_
with_hydrocephalus.html
• http://findarticles.com/p/articles/mi_m0FSZ/is_3_32/ai_n17213846/
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Carniocerebral Trauma

By-
Rahul Dhaker
Asst. Professor
Ramsnehi
College of
Nursing,
Bhilwara (RAJ)
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• Head trauma may occur during delivery and can
lead to a number of conditions for the infant
including
– caput succedaneum,
– cephalohematoma,
• Normal head deformity due to birth forces,
– subgaleal hemorrhage,
– subdural hemorrhage,
– Subarachnoid hemorrhage, and
– epidural hemorrhage.

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• Head trauma represents 80% or more of the
traumatic injuries leading to death in children
older than 1 year.
• Most pediatric head trauma occurs secondary to
motor vehicle accidents, falls, assaults,
recreational activities, and child abuse.

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 Definition
• Head injury includes any injury involves
– scalp,

– skull,

– meninges or

– any portion of the brain caused by external

force.
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• Head injuries fall into two categories:
– external injuries, usually involving the scalp
• The scalp is rich with blood vessels, so even a minor cut
there can bleed a lot. Sometimes the scalp’s veins leak fluid
or blood into (and under) the scalp. This appears as a "goose
egg" or swelling on the head. It may take days or even a
week to disappear.
– internal head injuries, which may involve the
skull, the blood vessels within the skull, or the
brain
• Cerebrospinal fluid (CSF) is a clear fluid that cushions the
brain from damage. But a severe blow to the head can
still knock the brain into the side of the skull or tear blood
vessels.
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 Causes of Head Injury
• According to different age group the cause of head
injury can be described as follows.
– Neonates- Birth injury, instrumental delivery

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– Toddler and preschooler- Falls from height, hard
object falling on the head or hits on head by hard
object.

– Older children- Automobile accidents, RTA, Sports,

and recreation injury, fall from height, crush injury,
fall of heavy object on head.

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 Type of Head Injury
• Fracture of skull
– IN neonate a typical ―ping-pong‖ fracture may occur
– Linear skull fractures
– Depressed skull fractures
– Diastatic skull fractures
• These are fractures that occur along the suture lines in the
skull. The sutures are the areas between the bones in the head
that fuse with the growth of the child. In this type of fracture,
the normal suture lines are widened. These fractures are more
often seen in newborns and older infants.
– Basilar skull fracture
• Intracranial hemorrhage R Dhaker, Asst. Professor, RCN 42
 Cont… Type of Head Injury

• Concussion of the brain ( Cerebral Concussion)

• Cerebral contusion

• Extradural hematoma

• Acute subdural hematoma

• Brain swelling

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 Clinical Manifestation
• The following are the most common symptoms of
a head injury.
• However, each child may experience symptoms
differently.
• The child may have varying degrees of symptoms
associated with the severity of the head injury.
• The symptoms of a mild head injury may
include:-

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Cont… Clinical Manifestation

• Mild head injury: •Nausea

– Raised, swollen area
•Problems with memory
from a bump or a bruise
– Small, superficial and/or concentration
(shallow) cut in the scalp •Change in sleep patterns
– Headache •Blurred vision
– Sensitivity to noise and
•"Tired" eyes
light
– Irritability •Ringing in the ears
– Confusion (tinnitus)
– Lightheadedness and/or •Alteration in taste
dizziness
•Fatigue or lethargy
– Problems with balance
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Cont… Clinical Manifestation

• Moderate to severe head injury (that requires

immediate medical attention)--symptoms may
include any of the above plus:
– Loss of consciousness
– Severe headache that does not go away
– Repeated nausea and vomiting
– Loss of short term memory, such as difficulty
remembering the events that led right up to and
through the traumatic event
– Slurred speech
– Difficulty with walking
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– Weakness in one side or area of the body
– Sweating
– Pale in color
– Seizures or convulsions
– Behavior changes including irritable
– Moderate to severe head injury (that requires
immediate medical
– Blood or clear fluid draining from the ears or nose
– One pupil (dark area in the center of the eye) looks
larger than the other eye
– Deep cut or laceration in the scalp

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 48
R Dhaker, Asst. Professor, RCN
Cont… Clinical Manifestation

– Open wound in the head

– Foreign object penetrating the head
– Coma (a state of unconsciousness from which a
person cannot be awakened; responds only minimally,
if at all, to stimuli; and exhibits no voluntary activities)
– Vegetative state (a condition of brain damage in
which a person has lost his thinking abilities and
awareness of his surroundings, but retains some basic
functions, such as breathing and blood circulation)
– Locked-in syndrome (a neurological condition in
which a person is conscious and can think and reason,
but cannot speak or move)

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 Diagnosis evaluation
• Obtains a complete medical history of the child
and family and asks how the injury occurred.
• Blood tests
• X-ray
• Magnetic resonance imaging (MRI)
• Computed tomography scan (also called a CT
or CAT scan).
• Electroencephalogram (EEG)

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 Treatment of a head injury
• Specific treatment of a head injury will be
determined by child's doctor based on:
– child's age, overall health, and medical history
– Extent of the head injury
– Type of head injury
– child's tolerance for specific medications, procedures,
or therapies
– Expectations for the course of the head injury
– opinion or preference of parent

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Cont… Treatment of a head injury

• Depending on the severity of the injury, treatment

may include:
– Ice
– Rest
– Topical antibiotic ointment and adhesive bandage
– Immediate medical attention
• Maintenance of airway
• Establishment of breathing
• Maintenance of circulation
• Assessment of neurological status
• NG feeding tube- to prevent abdominal distension of
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Cont… Treatment of a head injury
• Continuous monitoring of ICP
• Stitches
• Prevention and treatment of convulsion and fever
• Prevention of infection
– Hospitalization for observation
– Moderate sedation or assistance with breathing that
would require being placed on a breathing machine,
also called a mechanical ventilator or mechanical
respirator
– Diagnostic tests
– Surgery
• Craniotomy
• Subdural tap or V-P Shunt
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 Complication
• Shock
• Increased ICP
• Epidural hematoma
• Leptomeningeal cyst
• Visual disturbance
• Convulsion disorder
• Hydrocephalus
• Behavior disturbance
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