MILITARY MEDICINE, 185, 9/10:e1891, 2020

A Case Report of Hydrocephalus in a US Military Recruit

LT Jacqueline Clerc, MC USN ; LT Garrett M. Harp, MC USN ; CDR Michael Cathey, MC USN ;
LCDR Matthew Bauer, MC USN

ABSTRACT
We present a case of chronic non-communicating hydrocephalus (NCH) in a US military recruit. Non-communicating
hydrocephalus is a pathologic obstruction of cerebrospinal fluid (CSF) resulting in enlargement of the ventricles and
elevated intracranial pressure. The patient is an 18-year-old male recruit who was evaluated in the Naval Medical Center
emergency room for left hip pain and incidentally was found to have profound ventriculomegaly on head imaging. The

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diagnosis and evaluation of hydrocephalus is greatly dependent on clinical history and supported by radiographic imaging.
Based on these factors, one can determine if the hydrocephalus is either acute or chronic and communicating or non-
communicating.

BACKGROUND
The term chronic hydrocephalus encompasses any condition
in which ventriculomegaly occurs in association with chronic
low-grade elevation of cerebral spinal fluid (CSF) pressure
and is divided into communicating and non-communicating
sub-groups.1 Non-communicating hydrocephalus (NCH) is a
pathologic obstruction of CSF outflow resulting in “upstream”
enlargement of the ventricles and compression of the sur-
rounding brain tissue. While a detailed review of the com-
plex hydrodynamics of CSF is beyond the scope of this
case report, communicating hydrocephalus is theorized to be
due to decreased intracranial compliance, causing restricted
arterial pulsations and increased capillary pulsations.2 NCH
is often identified early in life, whether diagnosed in utero
via prenatal ultrasound or due to unexplained macrocephaly
in an infant. Etiologies are numerous and may be due to
congenital malformation as a result of premature birth. Risk FIGURE 1. MRI demonstrating ventriulomegaly in the patient.
factors include intraventricular hemorrhage, meningitis, head
injury, and brain tumors and Chiari malformation. sequences may be utilized to look for the potential causes
The diagnosis is made by radiographic imaging that for obstruction. For instance, high-resolution 3D sequences
demonstrates ventriculomegaly (see Fig. 1). Ventriculomegaly may be utilized to better evaluate lesions along the CSF
is defined radiologically by an Evans index (the ratio of outflow tract to hone the differential diagnosis which may
the frontal horn diameter to the maximum brain width alter treatment. Phase-contrast MRI (PC-MRI) may also play
from the inner skull) greater than 0.3. The earliest feature a role in such cases and has been shown to be useful for
of hydrocephalus is rounding of the frontal horns of the quantitative and qualitative evaluation of communicating and
lateral ventricles and dilatation of the temporal horns. non-communicating hydrocephalus.3
Conventional magnetic resonance imaging (MRI) sequences
are useful in evaluating the cause of NCH. Occasionally,
conventional MRI sequences may not clearly demonstrate the CASE REPORT
etiology for the obstruction; thus more specialized imaging The patient is an 18-year-old Caucasian US recruit with a med-
ical history notable for occasional headaches who presented
to a Military Medical Center emergency room for evaluation
Bureau of Medicine and Surgery, 34800 Bob Wilson Dr, San Diego, CA of left hip pain after a fall. He was running in the squad
92134
Previously presented as a poster at the Navy Chapter ACP meeting bay at the training command when he tripped on a bed and
The views expressed in this article are those of the author(s) and do not fell onto his left hip. He denied loss of consciousness. He
necessarily reflect the official policy or position of the Department of the reported that he was able to pick himself up after the fall and
Navy, Department of Defense, or the U.S. Government. continue to run without difficulty. However, later that day, he
doi:10.1093/milmed/usaa106
Published by Oxford University Press on behalf of the Association of complained of severe left hip pain. That night, the left hip pain
Military Surgeons of the United States 2020. This work is written by US was so significant that he experienced urinary incontinence
Government employees and is in the public domain in the US. in his bed because he did not think he could ambulate to the

MILITARY MEDICINE, Vol. 185, September/October 2020 e1891

 Case Report of Hydrocephalus in US Recruit

bathroom. He was in his 3rd week of recruit training when

this fall occurred. He denied any medication use aside from
occasional aspirin and ibuprofen for headaches. He denied any
medication allergies. His family history was notable for his
mother having an acoustic neuroma and his father with chronic
headaches.
Upon arrival to the emergency room, his chief complaint
was left-sided hip pain. On physical examination, he was alert
and in no apparent distress. He interacted appropriately and
was cooperative. Musculoskeletal exam revealed tenderness
to palpation of the greater trochanter of his left femur. He

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had no problems with passive range of motion of his left hip.
He had mild pain with active range of motion of his left hip.
Neurologic exam showed cranial nerves II through XII to be
grossly intact. He did not have any sensory or motor deficits FIGURE 2. Flair post MRI flattening for the midbrain from ventricu-
noted. His motor strength was five out of five in all of his major lomegaly and crowding of the cerebral aqueduct.
muscle groups.
A computed tomography (CT) scan without contrast of
the head was obtained since it was unclear at the time of
presentation if he sustained any head trauma during his fall.
The CT of his head showed massive ventriculomegaly of the
lateral and third ventricles. The fourth ventricle was within
normal limits. There was also fluid-filled expansion of the
sella turcica that was associated with marked effacement of the
cerebral sulci and cerebral parenchymal volume loss. There
was no acute hemorrhage, abnormal extra-axial collection,
or midline shift. Gray and white matter differentiation was
maintained.
A MRI study of his brain with CSF flow analysis was
subsequently completed for further evaluation. Mild periven-
tricular T2 signal was seen suggesting mild hydrostatic edema.
The midbrain was flattened and the fourth ventricle was nor-
mal in size (see Fig. 2). There was marked depression of the
floor of the third ventricle with funneling of the cerebral aque-
duct consistent with cerebral aqueduct stenosis (see Fig. 2). FIGURE 3. CT head without contrast – “Copper beaten” appearance to the
skull.
Flow-sensitive MRI sequences were unable to demonstrate
any appreciable flow of CSF across the cerebral aqueduct.
The MRI confirmed ventriculomegaly as a result of cerebral The patient’s imaging contained many of the classic features
aqueduct stenosis. consistent with chronic NCH including a “copper beaten”
The patient did well clinically. After a brief period of obser- appearance to the skull (see Fig. 3), marked dilatation of the
vation in the intensive care unit and neurosurgical consulta- ventricles, thinned and elevated corpus callosum, depression
tion, the patient was transferred to the general medicine ward. of the fornices, and inferior displacement of the floor of
The patient’s diagnosis of NCH was thought to be chronic in the third ventricle. This case is helpful in demonstrating the
nature due to minimal symptoms, which were thought to be clinical and diagnostic differences between acute and chronic
poor academic performance and poor coordination throughout NCH as well as NCH and communicating hydrocephalus.
childhood. Neurosurgical intervention was deferred during A significant difference between acute and chronic NCH
this hospitalization since there were no neurologic deficits. He is the clinical presentation. Acute NCH will present with
was discharged from the hospital to the training command. headaches, neurologic changes, nausea, and vomiting and if
Subsequently, he went through entry-level separation with a left untreated may lead to coma or death. These symptoms are
plan to seek continued care after separation. due to a rapid increase in intracranial pressure. In comparison,
chronic NCH typically has little to no symptoms due to the
gradual rise in intracranial pressure which is often compen-
DISCUSSION sated at the time of discovery.
This case is a notable presentation of chronic NCH in a As mentioned earlier, chronic hydrocephalus can be
young adult diagnosed incidentally during evaluation of a fall. divided into non-communicating and communicating

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 Case Report of Hydrocephalus in US Recruit
subtypes. Radiographic imaging is necessary in determin-
ing the type of chronic hydrocephalus. Communicating
hydrocephalus typically causes dilation of the entire ventricu-
lar system including the fourth ventricle, which is in contrast
to NCH where only the ventricles behind the obstruction
will be dilated. Another radiographic finding seen in chronic
NCH is a “copper beaten” appearance skull, which can be
radiographically confused with Luckenschadel skull. Luck-
enschadel skull is described as the internal skull with groups
of round, oval, or finger-shaped pits separated by ridges of
bone, which is associated with Chiari II malformations.4 MRI
is very useful in evaluating the etiology of the obstruction and
can give detailed information of the CSF flow.
NCH can be further classified by the level of obstruc-
tion, which will help guide providers’ evaluation. In this
patient the obstruction was determined to be at the cere-
bral aqueduct, which is commonly caused by congenital
stenosis, webs, membranes, cysticercosis, sequela of remote
hemorrhage, periaqueductal infective lesions, pineal gland
neoplasms, gliomas, and metastasis.3 Diagnosis is greatly
based on history and radiographic imaging. Lumbar punc-
ture is understandably contraindicated in the setting of
NCH.
As this patient was a recruit, it was important to review his
case in terms of suitability for service in the US military. The
U.S. Navy MANMED Chapter 15–57 history of congenital or
acquired anomalies of the central nervous system is disqual-
ifying. Due to this discovery of chronic NCH in this young
man, it was recommended that he not be allowed to participate
in military service.
Some of the documented complications of hydrocephalus
include syncopal events triggered by exertion.1 There are
reports of young adults with chronic hydrocephalus who die
suddenly and unexpectedly without any preceding symptoms,
in whom postmortem examination reveals massive ventricu-
lomegaly, but no uncal or tonsillar herniation and an absence
of midbrain hemorrhage or necrosis.1 These potential com-
plications support the disqualification of people with hydro-
cephalus. Due to the limited data of the prevalence of these
significant known complications, the decision for disqual-
ification of people with hydrocephalus cannot be revisited
yet.
MILITARY MEDICINE, Vol. 185, September/October 2020
Several options are available for treatment of NCH, includ-
ing third ventriculostomy, ventriculoatrial shunt, and ventricu-
loperitoneal shunt. However, each of these have their own
complications and require ready access to advanced neurosur-
gical care. Instances of the complications of ventriculoperi-
toneal shunting include central nervous system infection, ven-
tricular collapse, and damage to surrounding brain tissue.
These complications would also limit a person’s safety to
serve in the military.5
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CONCLUSION
Hydrocephalus is divided into acute or chronic and non-
communicating or communicating. Diagnosis of hydro-
cephalus and its evaluation are greatly dependent on a
thorough history and radiographic imaging. Chronic non-
communicating hydrocephalus diagnosed in adulthood is
uncommon and may be associated with serious complications.
This condition is not compatible with service in the military.
Per MANMED Chapter 15–57, a history of congenital
or acquired anomalies of the central nervous system is
disqualifying, which is supported by a review of the literature
due to the associated complications and treatment with
ventriculoperitoneal shunting or other neurosurgical inter-
ventions. Without further data on the prevalence of significant
complications from non-communicating hydrocephalus, the
current guidance of disqualification for military service cannot
be revised at this time.
REFERENCES
1. Edwards RJ, Dombrowski SM, Luciano MG, Pople IK: Chronic
hydrocephalus in adults. Brain Pathol 2006; 14(3): 325–36. doi:
10.1111/j.1750-3639.2004.tb00072.x.
2. Filho FEFM, Machado LDR, Lucato LT, Leite CC: The role of 3D
volumetric MR sequences in diagnosing intraventricular neurocysticer-
cosis: preliminary results. Arq Neuropsiquiatr 2011; 69(1): 74–8. doi:
10.1590/s0004-282x2011000100015.
3. Fowler JB. Ventriculoperitoneal Shunt. StatPearls [Internet]. https://www.
ncbi.nlm.nih.gov/books/NBK459351/. Published February 14, 2020;
accessed April 22, 2020.
4. Gaillard F. Copper Beaten Skull: Radiology Reference Article. Radiopae-
dia Blog RSS https://radiopaedia.org/articles/copper-beaten-skull?lang=
us. accessed April 22, 2020.
5. Chapter 15-57. In: US Navy MANMED.
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