THE BRAIN

 Cerebrum: is the largest part of the brain and is composed of right and left
hemispheres. It performs higher functions like interpreting touch, vision
and hearing, as well as speech, reasoning, emotions, learning, and fine
control of movement.

 Cerebellum: is located under the cerebrum. Its function is to coordinate

muscle movements, maintain posture, and balance.

 Brainstem: acts as a relay center connecting the cerebrum and cerebellum

to the spinal cord. It performs many automatic functions such as breathing,
heart rate, body temperature, wake and sleep cycles, digestion, sneezing,
coughing, vomiting, and swallowing.
HYDROCEPHALUS
 Hydrocephalus is a condition characterized by an excess of
cerebrospinal fluid (CSF) within the ventricular and subarachnoid spaces
of the cranial cavity.

 The term hydrocephalus is derived from two words: “hydro,” meaning

water, and “cephalus,” referring to the head.

 Hydrocephalus can be defined broadly as a disturbance of

cerebrospinal fluid (CSF) formation flow, or absorption, leading to an
increase in volume occupied by this fluid in the central nervous system.

 This condition could also be termed a hydrodynamic CSF disorder.

PRODUCTION OF CEREBROSPINAL FLUID

 Produced at constant rate 0.3 cc per minute

 about 20 cc per hour, 500 cc (1/2 quart) per day

 Not much different throughout childhood

 Most CSF produced by choroid plexus in Lateral ventricles

 Located within the ventricles inside the brain

 Circulates within the ventricles and eventually flows to the outside of the
brain

 Subarachnoid space
PATH OF CIRCULATION

CSF is produced by Choroid plexus in the lateral ventricles flows through

foramina of Monro to reach the third ventricle.

The fluid then flows caudally through the aqueduct of Sylvius and reaches
the fourth ventricle.

Through foramen of luschka and megentie it reaches the subarachnoid

space.

CSF is absorbed by Arachnoid villi.

THE FUNCTION OF THE CSF

 The CSF acts like a “sink”, effectively flushing waste

products as new fluid is secreted and reabsorbed

 A constant CSF helps to maintain a stable medium for

excitable cells (neurons)
CLASSIFICATION

There are two types of hydrocephalus:

 Non-communicating. In the non-communicating type

of congenital hydrocephalus, an obstruction occurs in
the free circulation of CSF. No connection between
ventricular space and subarachnoid space

 Communicating. In the communicating type of

hydrocephalus, no obstruction of the free flow of the
CSF exists between the ventricles and the subarachnoid
space; rather, the condition is caused by defective
absorption of CSF, thus causing increased pressure on
the brain or spinal cord.
 CAUSES

Hydrocephalus from birth

 Congenital hydrocephalus, when a baby is born with the condition, can be
caused by certain health conditions, such as spina bifida.
 Congenital hydrocephalus can also occur in babies born prematurely,
before week 37 of the pregnancy.
 Some premature babies have bleeding in the brain, which can block the
flow of CSF and cause hydrocephalus.
 Other possible causes of congenital hydrocephalus include:
 Genetic factors
 arachnoid cysts – fluid-filled sacs located between the brain or spinal cord
and the arachnoid membrane
 In many cases of congenital hydrocephalus, the cause is unknown.
 Hydrocephalus that develops in adults or children
(acquired hydrocephalus) is usually the result of an injury or illness.

 Possible causes of acquired hydrocephalus include:

 bleeding inside the brain – for example, if blood leaks over the surface of
the brain (subarachnoid haemorrhage)

 blood clots in the brain (venous thrombosis)

 meningitis – an infection of the membranes surrounding the brain and

spinal cord

 brain tumours

 head injury

 stroke
The pathophysiology of hydrocephalus occurs as follows:
 Normally, a delicate balance exists between the rate of formation and
absorption of CSF.
 In hydrocephalus, this balance is disturbed.
 CSF is formed mainly in the lateral ventricles by the choroid plexus and is
absorbed into the venous system through the arachnoid villi.
 CSF circulates within the ventricles and the subarachnoid space.
 An obstruction may occur in the free circulation of CSF; this blockage
causes increased pressure on the brain or spinal cord.
 The site of obstruction may be at the foramen of Monro, the aqueduct of
Sylvius, the foramen of Luschka, or the foramen of Magendie.
 If there is no obstruction, the condition may be caused by defective
absorption of CSF, thus causing increased pressure on the brain or
spinal cord.
CLINICAL FEATURES

 Poor feeding..
 Large head.
 Bulging of the anterior fontanelles. The anterior fontanelle becomes
tense and bulging, the skull enlarges in all diameters, and the scalp
becomes shiny and its veins dilate.
 Setting sun sign. If pressure continues to increase without intervention,
the eyes appear to be pushed downward slightly with the sclera visible
above the iris- the so-called setting sun sign.
 High-pitched cry.
 Irritability.
 Projectile vomiting.
Physical findings in children include the following:

 Papilledema : raised ICP

 Macewen sign: A "cracked pot" sound is noted on percussion of

the head.

 Unsteady gait: This is related to spasticity in the lower extremities.

 Large head: Sutures are closed, but chronic increased ICP will lead

to progressive macrocephaly.

 Unilateral or bilateral sixth nerve palsy is secondary to increased

ICP.
DIAGNOSIS

 Physical examination
 MRI
 CT
 Ultrasound
Pharmacologic Therapy

 The following medications are used to treat hydrocephalus.

 Diuretics. Acetazolamide (ACZ)(a carbonic anhydrase inhibitor )and furosemide

(FUR) treat posthemorrhagic hydrocephalus in neonates; both are diuretics also
helps to decrease secretion of CSF at the level of the choroid plexus.

 Anticonvulsants. Helps to interfere impulse transmission of cerebral cortex and

prevent seizures.

 Antibiotics. Culture and sensitivity dependent for shunt infections such as

septicemia, ventriculitis, meningitis, or given as a prophylactic treatment.
SURGICAL TREATMENT OF HYDROCEPHALUS

 The two most commonly used shunt systems are the

ventriculo-Atrial (VA) and ventriculo-peritoneal (VP)
shunts. The VP shunt is most commonly used as it is
simpler to place, extra tubing may be placed in the
peritoneum and the consequences of infection are less.
 The VA shunt must be accurately located in the atrium and requires
frequent revisions as the child grows to maintain the proper position of the
distal end. In addition, infection is a more serious complication with a VA
shunt as its location in the blood stream may lead to sepsis.
VP Vs VA SHUNT
Pre-op care:

 Accurate information is essential in the assessment of the child with

hydrocephalus.

 Head circumference.

 Neurologic and vital signs.

 Check the fontanelles. If the fontanelles are not closed, carefully observe
them for any signs of bulging.

 Monitor increase in intracranial pressure. Observe, report, and document

all signs of ICP.

 Proper aseptic techniques to be followed.

 Handle baby properly.

Post op care:
 Place the infant in flat position
 Check vital signs every 15-30 mts
 Assess neurological status and HC
 Monitor intake and output
 Oral can be started after bowel sounds returns
 Check for dressings.
 Monitor for fever,vomiting,increased heart rate,RR,poor feeding
 Assess for fontanele
 Prophylactic antibiotics
 Prevent constipation
 Handling the baby carefully while feeding and positioning.
MENINGITIS
Meningitis is defined as the inflammation of the meninges
covering Brain and spinal cord.
o Bacterial or pyogenic Meningitis:
It is caused by a wide variety of pyogenic bacteria like
Haemophilusinfluenza,Meningococcus,Pneumococcus,
Streptococcus etc.
Haemophilus Influenza and meningococcus together
account for 70% of all cases of Bacterial meningitis.
Bacterial meningitis is almost always a complication of
bacteremia occurring due to Pneumonia, Empyema,
Osteomyelitis and endocarditis. It is rarely seen but is
serious and can be life threatening.
o Aseptic Meningitis: It is caused by Virus, Fungi, and Protozoa.
It is relatively common and less serious .Its symptoms are
similar to common flu.

o Tubercular Meningitis: It is caused by mycobacterium

tuberculosis
Predisposing Factors:
o Children on immunosuppressive drugs
o Children with malignancies
o Immunocompromised children like babies of HIV
positive mothers
o Meningitis may follow trauma, invasive procedures,
lumbar puncture and penetrating head wounds
o Meningitis is common in infants and young children
because of their immature immune system.
PATHOPHYSIOLOGY

Infections from any part of the body like nasopharynx

Organisms invade surrounding blood vessels

Through blood ,organisms enter CSF

Infections spread through subarachnoid space

Inflammatory process begins

Increase CSF exudation in ventricles

Interference in CSF flow through ventricular aqueduct

Thrombophlebitis of cerebral vessels

Infection of cerebral cortex,cerebral Damage.and cranial

nerves may be affected.
Symptoms and Signs of Meningitis in Children
o Classic or common symptoms of meningitis in infants
younger than 3 months of age may include some of the
following:
o Decreased liquid intake/poor feeding
o Vomiting
o Lethargy
o Rash
o Stiff neck
o Increased irritability
o Increased lethargy
o Fever
o Bulging fontanelle (soft spot on the top of the head)
o Seizure activity
o Hypothermia (low temperature)
o Shock
o Hypotonia (floppiness)
o Hypoglycemia (low blood sugar)
o Jaundice (yellowing of skin)
o Classic symptoms in children older than 1 year of age
are as follows:
o Nausea and vomiting
o Headache
o Increased sensitivity to light
o Fever
o Altered mental status (seems confused or odd)
o Lethargy
o Seizure activity
o Coma
o Neck stiffness or neck pain
o Bulging Fontanel
o Symptoms older than 3 years of age
o Fever, Chills, Malaise
o Headache, Vomiting, Papilledema
Brudzinski’s Sign: With the patient in supine position on
passive flexion of neck there is involuntary bending of hip
and knees.
o Kernig’s Sign-With the patient in supine position
and hips flexed ,passive straightening of the leg at
knee causes active resistance and back pain.
o Photophobia, diplopia, other visual problems due to
cranial nerve irritation
o Delirium, deep coma or stupor due to cerebral
edema and increased intracranial pressure
VIRAL MENINGITIS
Symptoms of viral meningitis most commonly resemble
those of the flu (fever, muscle aches, cough, headache but
some may have one or more of the symptoms listed above
for bacterial meningitis), but the symptoms are usually
considerably milder.
Diagnosis:
o Lumbar puncture
o Blood examination
o Urine may be obtained to determine if any infection is
present in the child's urinary tract system.
o A chest X-ray film may be taken to look for signs of
infection in the child's lungs.
o A CT scan is sometimes necessary if any of the
following is present or suspected:
o Trauma
o Increased brain pressure
o Neurologic problem
o Brain abscess
o Tumor
 MANAGEMENT
Antibiotics --- Inj.ceftriazone 7-14 days
Nursing Management
o Isolate the child
o When the child is admitted with suspected
meningitis ,the nurse should isolate the child in order
to protect the other patients from infections
o Proper isolation techniques and strict hand washing
needs to be observed and the parents need to be
instructed accordingly
o Nobody with the upper respiratory tract infection
should attend the child as he is already infected
o Control seizures and protect the child from injury
o Monitor the child’s level of consciousness
o Side rails of bed should be up to prevent falls
o Never leave the child alone
o Provide comfort and rest
o The child may have photophobia so avoid bright light in
patients room
o The environment of the child’s unit should be calm
quiet
o Avoid use of pillow as the child is having nuchal
rigidity and giving pillow under the head may cause
discomfort
o Position the child on side so as to prevent any aspiration
o Care should be taken while moving and lifting the child
as this may lead to pain and discomfort
o Provide passive exercises to the child
o Other comfort measures include frequent mouth care,
changing of position to prevent bed sores, use of air or
water mattress and keeping the skin clean and dry.
o Monitor the child’s condition
o Vital signs should be monitored frequently
o Assess the neurological status and level of
consciousness frequently

o Assess the fontanels and measure the head circumference

daily. An increase in head circumference indicates
hydrocephalus
Complications
o Subdural effusion
o Cerebral infarction
o Cranial nerve Palsies including deafness and optic
neuritis
o Encephalitis,Endocarditis,Brain abscess
o SIADH
o Hydrocephalus
SEIZURE DISORDER
 A seizure is defined as a transitory disturbance in
consciousness or in motor, sensory, or autonomic function
caused by uncontrolled electrical discharges in the brain

 Epilepsy refers to disorders characterized by recurrent

seizures rather than a single seizure
Etiology
 Early neonatal period
• Birth Asphyxia
• Intraventricular haemorrhage
• Pyridoxime
deficiency,Hypogycemia,Hypocalcemia,Hyponatremia
• IEM

 Late neonatal Period:

• Hypocalcemia,Hypomagnesemia,Hypoglycemia
• Kernicterus
• Meningitis,Septicemia
• Intrauterine infections
• IEM
 From one month to three years
• Fever
• Infections of CNS
• Post vaccination encephalopathy
• Metabolic causes like
dehydration,dyselectrolemia,Alkalosis,Hypokalemia.
• Brain lesions like neoplasms, abscess
• Heat stroke
CLASSIFICATION

SEIZURES

PARTIAL GENERALIZED

1. PARTIAL SEIZURES

 Simple seizures

 complex seizures
2.GENERALIZED SEIZURES

 Absence

 Tonic Clonic seizures

 Akinetic seizures

 myoclonic seizures
PARTIAL
 Simple - motor/sensory movements often begins with thumb or arms.
Person remains alert

 Complex - person experiences aura, with altered consciousness during

seizure and confusion following the seizure
Symptoms:
• Abnormal muscle contractions
• Muscle contraction and relaxation
• One side of the body is affected
• Abnormal head movements
• Forced turning of head
• Automatism
• Repetitive purposeless movements
• Starring,chewing,swallowing without any cause.
 Abnormal sensations
• Numbness,tingling,crawling sensations of skin
• May occur in only one part of body or may spread
• Hallucinations
• Changes in vision
• Changes in mood/emotion Confusion in post ictal phase
GENERALISED
 Absence seizures - also called petit mal seizures(<15
sec.) staring episodes, lip smacking, fluttering eyelids.

 Atonic seizures - sudden loss in muscle strength, often

resulting in a fall

 Myoclonic seizures: sudden repeated contractures of

muscle of head and extremities
 Tonic seizures –
• usually occur during sleep involving most of the brain,
causing increased muscle tone ,
• Eyes roll upward or deviated to one side,
• Pupils dilate
• Bladder and bowel in continence.

 Clonic seizures - rhythmic jerking movements of the

entire body

 Tonic-clonic seizures - also known as “grand mal”

seizures, whole-body jerking movements with loss of
bowel, bladder, and consciousness, muscle contractures
 FEBRILE SEIZURES
DIAGNOSIS

 History and physical - emphasis on seizure event is most

valuable tool

 Lab tests - complete blood cell count, metabolic panel

 Brain imaging studies - Computed tomography scan,

magnetic resonance imaging
 Electroencephalogram - to correlate with seizure activity
and electrical discharges in the brain

 Possibly a spinal tap for spinal fluid specimen

TREATMENT

 ANTI EPILEPTICS
 Help the child to lie down.
 Remove glasses or other harmful objects in the area.
 Do not try to put anything in the child's mouth. In doing so, you may injure
the child or yourself.
 After the seizure ends, place the child on one side and stay with the child
until he or she is fully awake. Observe the child for breathing.
 If the child has a fever, Paracetamol may be given orally.
 Do not try to give food, liquid, or medications by mouth to a child who has
just had a seizure.
SPINA BIFIDA
What is spina bifida?

Spina bifida occurs because of the defect in orderly closure

of vertebral column and spinal cord during 4th -6th week of
gestation”.
INCIDENCE AND ETIOLOGY

It is the most common developmental defect of CNS

occurring in about 1or 2 per live births. It occurs most
commonly in lumbosacral area.

Etiology:
• Unknown
 Genetic Factors
 Maternal Age : pregnant mothers of >35 yrs and < 20yrs
 Environmental Factors: Radiations increase the risk of
defective neural tube development.
 Diet :Folic acid deficiency
 Medications-Anti seizures
CLASSIFICATION

SPINA BIFIDA

SPINA BIFIDA SPINA BIFIDA

OCCULTA CYSTICA

Meningocele

Myelomeningocele
Spina bifida Occulta:
Occulta" means hidden. The mildest form, spina bifida
occulta results in a small separation or gap in one or
more of the bones of the spine (vertebrae).
Many people who have spina bifida occulta don't even
know it, unless the condition is discovered during an
imaging test done for unrelated reasons.
Spinal cord and meninges are normal
Meningocele
In a form of spina bifida called meningocele, the protective
membranes around the spinal cord (meninges) ,CSF push
out through the opening in the vertebrae, forming a sac
filled with fluid.
But this sac doesn't include the spinal cord, so nerve
damage is less likely, though later complications are
possible.
Myelomeningocele
It is sac like protrusion of spinal cord,CSF,Meninges
through the spinal cleft.
Clinical features:
Spina Bifida Occulta:
 A dimple in the skin or growth of hair over malformed
vertebra
 As the child grows ,may develop foot weakness or
disturbances of bladder and bowel

Spina Bifida Cystica:

Meningocele:
 An external cystic defect can be seen at the back. The
sac is composed of meninges and CSF
 Spinal cord and nerves are normal
Myelomeningocele:
 Herniated mass is present over the vertebral column
mainly in lumbar region.
 Loss of motor control and sensation occurs
Thoracic lesion may cause total flaccid paralysis
Sacral lesion leads to weakness of lower limbs.
 Bladder and bowel may or may not be affected
 Congenital skeletal problems like club
foot,Kyphosis,scoliosis
 Developmental delays.
Diagnosis:
Prenatal :
 USG
 Amniocentesis-Alpha fetoprotein Increase

when an open neural tube defect is present, the amniotic

fluid contains an elevated amount of AFP because the skin
surrounding the baby's spine is gone and AFP leaks into the
amniotic sac.
After birth:
 On neonatal examination, a sac is found on the back
 If the sac becomes translucent when the light source is
held it is meningocele. If the sac does not become
translucent it is myelomeningocele.
 CT scan and MRI
 CBC
 Neurological assessment for motor response, sensory
reactions.
 Developmental assessment to detect any delay in
milestones.
Management
 No intervention is needed-Spina bifida occulta
 Spina bifida cystica –Laminectomy and closure of the
defect and removal of sac is done within 24 -48 hrs of
birth.