Hydrocephalus (1) (2)

hydrocephalus

1. Hydrocephalus Dr. Akshita (PT) M.P.T (Cardiopulmonary) D.C.P.T Certified BLS & ACLS, AHA

2. D efinition Hydrocephalus  is excessive accumulation of cerebral spinal fluid (CSF) within the cranial cavity which results in ventricular enlargement due to disturbance of production, flow or reabsorption of CSF. It results due to imbalance of production and absorption of CSF .

3. CSF- Cerebral Spinal F luid CSF is secreted by the choroid plexus within the ventricles. CSF fills the subarachnoid spaces, protecting and cushioning the brain . CSF volumes – forms at a rate of 500 ml/day.

4. CSF in ventricles

5. Course of CSF CSF Secreted from lateral ventricles, third and fourth ventricles. Flows in cadual direction through ventricular system. Exists from foramen of L ushka and M agendie. Reaches to cerebral and spinal subarachnoid space. There gets absorbed via arachnoid villi into venous system.

6. Classification Obstructive Hydrocephalus : Obstruction of CSF flow within the ventricular system. Communicating Hydrocephalus : Obstruction of CSF flow out with the ventricular system, i.e. ventricular CSF communicates with the subarachnoid space

7. Causes Obstructive Communicating Congenital Acquired

8. Causes Congenital Intracranial bleeds Intraventricular hemorrhage Intrauterine infections- Rubella, Cytomegalovirus Midline tumors obstructing CSF flow Congenital malformation: Aqueduct stenosis or forking ( Aqueduct stenosis is a narrowing of the aqueduct of Sylvius which blocks the flow of cerebrospinal fluid (CSF) in the ventricular system) . Dandy walker syndrome: Atresia (closed/absent) of foramina of Magendie and Lushka. Arnold- C hiari syndrome (malformation of medulary spinal junction).

9. Acquired hydrocephalus Acquired aqueduct stenosis: Adhesions following infection or hemorrhage. Supratentorial masses causing tentorial herniation. Chronic and pyogenic meningitis. Abscesses/ granuloma. Post intraventricular hemorrhage- haematoma. Tumors – Ventricular (colloid cyst), tumors of pineal region, posterior fossa. Arachnoid cysts Causes

10. Communicating Thickening of leptomeninges or involvement of arachnoid granulation. Infections- Pyogenic, TB, Fungal. Subarachnoid hemorrhage- traumatic or post operative. Carcinomatous meningitis. Increased CSF viscosity- due to high protein content. Excessive CSF production- choroid plexus papilloma Causes

11. Etiology 1. Excessive CSF production (rare) Choroid plexus papilloma/carcinoma 2. Obstructive hydrocephalus Hydrocephalus—when there is an obstruction to the flow of CSF through the ventricular system Lesions within the ventricle. Lesions in the ventricular wall. Lesions distant from the ventricle but with a mass effect.

12. 3. Communicating hydrocephalus (impaired absorption) Post- haemorrhagic CSF infection (especially bacterial and tuberculous) Raised CSF protein Etiology

13. P athophysiology

14. Results in : Raised ICP White matter damage Gliotic scarring Some CSF absorption occurs from periventricular region P athophysiology CSF flow obstruction/ CSF impaired absorption Ventricular dilation CSF permeates through the ependymal lining into periventricular white matter.

15. Clinical features

16. Infants & young children Acute onset: irritability, impaired conscious levels, vomiting. Gradual onset: Mental retardation, failure to thrive (undergrowth or inability to growth) Enlargement of Head (Ventricular dilation) Increased ICP (Intra cranial pressure) Tense anterior fontanel, delayed closure. Headache, nausea, fever. Seizures. Sunset sign. Papilloedema. Clinical features

17. On observation and examination Cracked pot sound on skull percussion. Increased head circumference. Thin scalp with dilated veins. Lid retraction Impaired upwards gaze Clinical features Sunset Sign

18. Sunset sign Seen in up to 40% of children with obstructive hydrocephalus  and 13% of children with shunt dysfunction

19. Juvenile & Adults Acute sign: Impaired upwards gaze Increased ICP (Intra cranial pressure) Signs of increased ICP- Headache Vomiting Papilloedema Deterioration of conscious level Irritability Swelling Fever Clinical features

20. Gradual sign: Dementia, gait ataxia, incontinence. Ventricular dilation Personality and behavioral changes Visual disturbances Confusion Sleepiness Clinical features

21. Ventricle D ilation

22. Hydrocephalus ex vacuo Hydrocephalus ex vacuo, also known as compensatory enlargement of the CSF spaces, is a term used to describe the increase in the volume of CSF, characterized on images as an enlargement of cerebral ventricles and subarachnoid spaces, caused by encephalic volume loss. It occurs when there is damage to the brain caused by stroke or injury, and there may be an actual shrinkage of brain substance. Although there is more CSF than usual, the CSF pressure itself is normal in hydrocephalus ex vacuo .

23. Normal Pressure H ydrocephalus Normal pressure hydrocephalus (NPH) is a condition that is caused by an abnormal build up of cerebrospinal fluid (CSF) in the ventricles (cavities or spaces) of the brain. Cerebrospinal fluid is a clear liquid that circulates around the brain and spinal cord, cushioning and protecting them from damage. The differences between NPH and other forms of hydrocephalus is that even though there is a larger than normal amount of CSF, the pressure inside the ventricles remains the same.

24. D iagnosis

25. X-ray shows E nlarged size of head Suture width Copper beating (evidence of chronic raised pressure) D iagnosis

26. CT Scan shows Ventricular enlargement Lateral and 3 rd ventricular dilation suggests aqueduct stenosis or posterior fossa mass. Generalized dilation suggests a communicating hydrocephalus or 4 th ventricle obstruction. Dilated ventricles. D iagnosis

27. Ultrasonography T hrough anterior fontenalle shows ventricular enlargements in infants. MRI ICP Monitoring Developmental assessment and psychometric analysis D etects impaired cerebral function and provides base line for future comparison D iagnosis

28. Management Medical Management Surgical Management Physiotherapy Management

29. Management Medical M anagement Acetazolamide: decrease CSF production. Isossorbide : increases CSF absorption . Surgical Management If there is obstructive or non-communicating hydrocephalus removal the obstruction is preferred .

30. Surgical Management Ventriculoperitoneal shunting- Shunts cause cerebrospinal fluid to flow unidirectional under a valve system to peritoneal cavity in abdomen. Common causes for failure are infection, obstruction, over-drainage, disconnection and loculated cerebrospinal fluid collection.

31. Ventriculoatrial shunting- F irst choice for those who are unable to have abdominal distal catheters. It runs from ventricles via jugular vein into the right atrium of the heart. High risk procedure. Complications such as renal failure or thrombosis of great vein. Surgical Management

32. Endoscopic Third Ventriculostomy (ETV) A n alternative therapy to cerebrospinal fluid shunting. Minimally invasive procedure. Ventriculostomy is to create an opening in the floor of the third ventricle to subarachnoid space, usually the trapped fluid begin to absorb right after the opening. Surgical Management

33. Physiotherapy management Regardless of medical & surgical management, children with hydrocephalus still have some disabilities. Therefore, early intervention and rehabilitation is essential. Goals Improve functional skills Improve developmental skills Reducing secondary impairment Maximize independency Perform activities of daily living Improve mobility

34. Gait training Muscle Tone management Strength and endurance training Bowel and bladder training Postural training Balance and coordination training bed mobility and transfer training such as sitting to standing Functional mobility training Use of assistive devices and mobility equipment if necessary Physiotherapy Intervention

35. Motor control  Achieving delayed developmental milestone Behavioral training Physiotherapy Intervention

36. Thank You