Dr. Ummu Atiah, Sp.

S
 Definition
Hydrocephalus is an increase in the
cerebrospinal fluid. This results
from either
(a) Increased production (rare)
(b) Impaired absorption
(common)
 Formation
CSF is made by the choroids plexus of the
lateral and 4th ventricles. It travels inferiorly
form the lateral to the 3rd ventricle through the
aqueduct of Sylvies, to the 4th ventricle and
finally exits the ventricular system through the
foramina of Luschka and Magendie into the
subarachnoid space. From here, it flows
superiorly until it gets absorbed by subarachnoid
granulations into the sinuses of the venous
system.
Figure 1 Here is the direction of flow of the CSF from the foramina of luschka
& Magendie to the subarachnoid granulations. One can see that a tumor of
the cerebellum could impinge upon the 4th ventricle and cause an obstructive
hydrocephalus. This occurs commonly with posterior fossa tumors.
We can see the subarachnoid granulations. If they are obstructed
a communicating hydrocephalus occurs.
Figure 1.5 Here we see quite clearly how easily a cerebellar
tumor could impinge upon the 4th ventricle and cause an
obstructive hydrocephalus.
 Pathological effects
CSF penetrates through the
ependymal lining into per-
ventricular white matter causing

(A) Raised ICP

(B) White matter damage and
glial scarring
 Figure 3 Here we see a gross coronal section of a brain with
hydrocephalus illustrating the gross dilatition of the lateral ventricles
at the level of the temporal lobes. At this point the lateral ventricles
should not be visible.
 Classification
Obstructive:obstruction within the
ventricular system
Communicating: the obstruction is in the
subarachnoid space or venous sinuses
or there is increased CSF production
as in a choroids plexus papilloma.
 Clinical features
Infants & young children:
Acute onset-irritability, impaired conscious level, and vomiting
Gradual onset- mental retardation and failure to thrive

In general there is :
increased skull circumference and radiographic evidence of mal-
fusion of cranial sutures.
lid retraction, and impaired ability for upward gaze.
 Investigations
: suggests a communicating hydrocephalus.
x-ray: skull size increased and suture width
increased. There can be evidence of chronic raised
ICP resulting in erosion of the posterior clinoid
processes.

CT scan:
The pattern of ventricular enlargement can help
delineate the cause:
Lateral & 3rd ventricle dilatation
normal 4th ventricle: suggests aqueduct stenosis
deviated or absent 4th ventricle: suggests
posterior fossa tumor
Generalized dilatation
 .
Here we see a cranial X-ray with radiolucency, pointing to malfusion of
the coronal suture to hydrocephalus and the resulting raised intracranial
CT Scan
 Management
Acute onset: ventricular drainage,
ventriculo-peritoneal shunt, or lumbar
puncture( if intracranial mass lesion is not
suspected)

Gradual onset: ventriculo-peritoneal shunt

and of course removal of lesion if possible

Ventriculo- peritoneal shunt: a catheter is

inserted into the peritoneum and tunneled
subcutaneously into the reservoir, which is
in contact with another catheter that lies
in the foramen of Munroe.
 Juvenile & adult:
Acute onset : signs symptoms of
increased ICP- headache,
vomiting, papilledema and
deteriorating conscious level, as
well as impaired upward gaze.

Gradual onset: this can result in

dementia, gait ataxia, and
incontinence.
 Pathological effects
CSF penetrates through the ependymal
lining into per-ventricular white matter
causing
(A) Raised ICP
(B) White matter damage and
glial scarring
 Prognosis
Theprognosis for hydrocephalus
depends on :
thecause, the extent of symptoms, and
the timeliness of diagnosis and
treatment.
Ingeneral, the earlier hydrocephalus is
diagnosed, the better the chance for
successful treatment.