HYDROCEPHALUS

It's about HYDROCEPHALUS
TO EXPLAIN ANATOMY OF HUMAN BRAIN�
TO INTRODUCE HYDROCEPHALUS
TO DEFINE HYDROCEPHALUS
TO EXPLAIN INCIDENCE OF HYDROCEPHALUS
TO EXPLAIN ETIOLOGY OF HYDROCEPHALUS
TO EXPLAIN PATHOPHYSIOLOGY OF HYDROCEPHALUS
TO EXPLAIN CLINICAL MANIFESTATION OF HYDROCEPHALUS
TO ENLIST DIAGNOSIS & DIAGNOSTIC EVALUATION FOR HYDROCEPHALUS
TO DESCRIBE MANAGEMENT OF HYDROCEPHALUS
TO EXPLAIN COMPLICATION & PROGNOSIS OF HYDROCEPHALUS

1. HYDROCEPHALUS MISS. BHAWANA SUNIL HAJARE BSC. NURSING 3 rd YEAR C O L L EGE O F N U R SING P A D H A R H O S P ITAL B E T U L

2. TO EXPLAIN ANATOMY OF HUMAN BRAIN TO INTRODUCE HYDROCEPHALUS TO DEFINE HYDROCEPHALUS TO EXPLAIN INCIDENCE OF HYDROCEPHALUS TO EXPLAIN ETIOLOGY OF HYDROCEPHALUS TO EXPLAIN PATHOPHYSIOLOGY OF HYDROCEPHALUS TO EXPLAIN CLINICAL MANIFESTATION OF HYDROCEPHALUS TO ENLIST DIAGNOSIS & DIAGNOSTIC EVALUATION FOR HYDROCEPHALUS TO DESCRIBE MANAGEMENT OF HYDROCEPHALUS TO EXPLAIN COMPLICATION & PROGNOSIS OF HYDROCEPHALUS

3. The human brain- * Bony skull forms the strongest covering & provides primary protection to brain. * It is an expansible structure in impels and small children due to incomplete classification of skull bones. * Rigid in older children and adolescence. Parts of brain- 1 . The cerebrum cerebral cortex- outermost layer of brain cells.( thinking & voluntary movements). 2. The brain stem is between the spinal cord and the rest of the brain. Basic function like breathing and sleep are controlled here. Medulla - sensory & motor tracts, breathing & cardiovascular centers, regulate consciousness & arousal. Pans - sensory & motor tracts. Midd brain - sensory & motor tracts, movements of head, eyes & trunk, response to visual stimuli. 3. The cerebellum is at the base & the back of the brain. The cerebellums' responsible for coordination & balance. 4. Diencephalon- Thalamus helps regulate motor function & maintenance of consciousness. Hypothalamu s releasing hormones & control of ANS. Epithalamus Pinal gland(secrete melatonin).

4. FUNCTIONAL ORGANIZATION OF CEREBRAL CORTEX Fontral lobes - Fontral lobes are responsible for problem solving and judgment and motor function. Parietal lobes- Parietal lobes Manage sensation, hand writing and body position. Temporal lobes- Temporal lobes are involved with memory and hearing. Occipital lobes - Occipital lobes contain the brain visual processing system.

5. BLOOD SUPPLY OF THE BRAIN 1- INTERNAL CAROTID ARTERY - Branches into various brain segment. 2- VOLUME OF BLOOD TO BRAIN CONSTITUTE 17% of cardiac output and supplies brain with 20% oxygen. ebb

6. CEREBROSPINAL FLUID • The normal amount of CSF is about 150ml. • CSF formed by choroid p l e x us. • Absorb ed by arachnoids villi. • Normally about 500ml of CSF formed everyday an equal amount is absorbed.

7. NORMAL CSF CIRCULATION Lateral ventricle 3 rd ventricle Foramina of monro Aqueduct ( Sylvius ) 4 th Ventricle Central canal of spinal cord Subarachnoid space Reabsorbed in venous sinuses by arachnoids villi Foramina of lulschka F o r a m i n a o f Magendie

8. HYDROCEPHALUS

9. INTRODUCTION The term hydrocephalus is derived from the greek word " Hydro " meaning w a t e r and c e p h a l u s m e a n i ng h e a d As the name implies, it is a condition in which the primary characteristics is excessive accumulation of fluid in the brain. Hydrocephalus is the condition cause by an imbalance in the production and absorption of CSF in the ventricular system. When production is grater then absorption, CSF accumulate within the ventricular system ,usually under increase pressure ,producing passive dilation of the Ventricles

10. 3. The CSF is secreted by the choroid clexus within the ventricul by ultra filtration and active recretion it passes from the lateral ventricul to the 3rd & 4th ventricul and exite from foramen of luschka and maggendie into the Basal cisterns and then the cerebral and spinal subarachnoid spaces where it is absorb via the arachnoid space where it is absorb via the arachnoid villi(Granelation) into the venous channels and sinuses. About 20ml of CSF is secreted in an hour and it's turnover is 3 or 4 time's in a day.

11. DEFINITION According to Marlin , " A condition in which fluid accumulate in the brain, typically in young children, enlarging the head and sometimes causing brain damage ". According to Parul dutta , " A condition resulting from imbalance in CSF production and absorption ". According to Ghai , " Hydrocephalus is the abnormal accumulation of cerebrospinal fluid in the intracranical spaces ".

12. INCIDENCE It is found in 1-3 of every 1000 born children in world wide. Occurs in 80-85% children born with meningomyelocele . Incidence is equal in males & females.

13. ETIOLOGY Hydrocephalus results from an imbalance between production and absorption of cerebrospinal fluid. There are 2 types:- Communicating Hydrocephalus. Noncommunicating hydrocephalus.

14. Communicating Hydrocephalus There is no blockage in the CSF pathway but reabsorption may be affected. Excess CSF may be produced in papiloma of choroid plexus. Obstruction or noncomminicating Hydrocephalus:- The block is at any level the ventricular system commonly at the level of aqueduct or foramina of luschka & magendle . In obstructive Hydrocephalus, the ventricles are dilated above the block in cerebral atrophy, Ventricles are dilated but prcssux is not raised(Hydrocephalus ex vacuo ). Bleeding inside the brain for eg . If blood leaks over the surface of the brain ( subarachnoid hemorrhage). Blood clots in the brain ( venous thrombosis). Meningitis – an infection of the membranes surrounding the brain & spinal cord. Brain tumors. Head injury. Stroke.

15. Hydrocephalus may occur due to congenital or acquired causes/ etiology- 1. Congenital Hydrocephalus- It occur due to the following Intrauterine infections- mainly in rubella , toxoplasmosis cytomegalovirus Congenital brain tumor obstructing the CSF flow. Intracranial hemorrhage . Congenital malformations like aqueduct stenosis , Arnold chiari malformation.( displacement of the brainstem and cerebellum through foramen magnum).Dandy walker anomaly (congenital septum or membrane blocking the outlet of 4 th ventricle). Malformations of arachnoids villi . 2. Acquired Hydrocephalus- It occurs usually following the conditions. Inflammation- Meningitis, encephalitis. Trauma- Brain injury, head injury, intracranial hemorrhage. Neoplasm- Space occupying lesions like tuberculoma, subdural hematoma or absorbs, gliomas , ependymoma , astrocutoma , choroid plexus papiloma pseudo tumor cerrbri . Chemical – hypervitaminsis A. Connective tissue disorder –hurler syndrome, achondroplasia . Degenerative abophy of brain- hydrocephalus ex vaccuo . Anterior venous malformation & rapture aneurism, cavernous sinus thrombosis.

16. PATHOPHYSIOLOGY OF CSF FLUID Impaired absorption. Obstruction of flow through ventricular system. Increased accumulation of CSF . Dilatation of ventricles & cortex can atrophy. Increased CSF in ventricular system. Compress brain against cranium. If this occur before fusion of cranial sutures these can be: Enlargement of skull Dilation of ventricles. If sutures are previously closed Sagital suture may become opened.

17. CLINICAL MANIFESTATIONS Infants- Early Abnormally rapid head growth. Bulging fontanels (tense. Non pulsatile ) Dilated scalp veins. Separated sutures. McEwen sign ( cracked pot sound on percussion of skull near the junction of the fontal, temporal & parietal bones). Thinning of skull bones. Poor head control. Later in infancy Fontal enlargement Depressed eyes When the third ventricle dilates, the child can present with paranoid syndrome (up gaze palsy with a normal ventricle doll response). The sitting sun sign ( paranoid syndrome with lid retraction & increased tonic down gaze). Pupils sluggish. Unequal papillary response to light. Older children Headache on awakening Nausea & vomiting Lethargy Apathy.

18. DIAGNOSIS History collection Physical finding in infants include the following. Vital sign- Bradycordia due to pressure on brain stem. Systemic hypertension. Altered respiration & sometimes apnea. Head Head enlargement ( HC>2 cm per month in months). Disjunction of sutures. Dilated scalp veins. Tense fontanelle , anterior fontanelle bulging. In older children Large head- sutures are closed , but chronic increased ICP will lead to progressive macro cephaty . McEwen sign- A “ cracked pot” sound noted on percussion of the head( open fontanels). As long as the anterior fontanel is open i.e. up to 18 months, the test will be positive.

19. 3. Trans illumination- translucency extending beyond 2.5cm in fontal area or over 2cm in occipilul are is abnormal. Eyes Setting-sun sign- in infonts , it is characteristic of increased intracranial pressure(ICP), Ocular globes are deviated downward, the upper lids are retracted, and the white sclera may be visible above the iris. Papilledema - If the raised ICP is not treated, this can lead to optic atrophy & vision loss. Failure of upward gaze. Unilateral or bilateral sixth nerve palsy ( abducens ) is secondary to increased ICP.(convergent drabismus ). Upper and lower limbs Increased limbs tone –Spasticity preferentially affects the lower limbs. The cause is stretching of the per ventricular pyramidal tract fibers by hydrocephalus. In children Unsteady gait – this is related to spasticity in the lower extremities. Pyramidal signs in lower limbs due to stretching of pyramidal tract fibers. Exaggerated plantar reflex & deep tendon reflexes of lower limbs along with increased tone of lower limbs.

20. DIGNOSTIC EVALUATION Lab test Ultrasound Magnetic resonance imaging (MRI) Computerized tomography (CT) scan. X-RAY of skull. Physical examination. Opthalmoscopy . Lumbar puncture- Insertion of spinal needle into subarachnoid space between the lower lumber vertebrae. CEREBRAL SPINAL FLUID Normal CSF Clear odorless WBC’s 0-5 Protein 15 to 45 Glucose 50-80 Pressure 50 to 180. Abnormal CSF Turbid cloudy WBC’S 1000-2000 Protein 100-500 Glucose lower than blood sugar. Pressure 180 or greater.

21. MANAGEMENT Management of HYDROCEPHALUS is directed towards. Reducing intracranial pressure. prevention & management of complication. Managing problems caused by the problem. Medical Management- Medical management include use of diuretic ( Acetazolamide & furosemide   ) this medicine provide temporary relief. Surgical management- A shunt is made up of radio plastic and has ventricular catheter, pressure value, pumping chamber and distal catheter that directs the flow of CSF from the ventricles to other areas of body from where it is absorbed. Endoscopic third ventriculostomy . Choroid plexectomy . Ventriculo -peritoneal shunt. ( vp shunt ) Ventriculatrial shunt. Ventriculopleural shunt. Ventriculo gall bladder shunt. Ventriculostomy & choroid plexectomy have been performed with variable results. Surgical shunts are the treatment of choroid at the present time. Intracranial or extracranial shunt is done to bypass the obstruction and to divert the CSF from the ventricular system to other compartment. The most commonly performed extracranial shunt is ventriculoperitoneal shunt. (VP shunt) Intrauterine surgical intervention in fetal hydrocephalus has not yet given good results.

22. Nursing management- Explain the family about the management required for the disorder. Pre operative care Measure the head circumference daily. Palpate the fontanele for evidence of increased intracranial pressure. Assess the pupilary response level of consciousness. Monitor vital signs regularly. Provide calm & quit environment. Present the child from nosocomial infection. Change the infant position frequently. 3. Post operative care- Place the infant in flat position to prevent rapid CSF damage. Check vital signs every 15-30 minutes in immediate post- operative period. Assess the neurological status. Assess the head circumference regularly. Oral rehydration must be started after the bowel sound response. Check dressing for any drainage. Teach parents about care of the child at home .

23. Nursing Diagnosis Risk for injury related to increased ICP. Risk for impaired skin integrity related to pressure from physical immobility. Altered nutrition less than body requirement related to reduce oral intake & vomiting. Anxiety related to the abnormal condition & surgical interventions. Risk for fluid volume deficit related to CSF drainage. Ineffective family coping related to life- retaining problem of infant. Complication Seizures Herniation of brain. Persistent increased ICP. Developmental delay. Neurological deficits. Motor & intellectual handicaps. Visual problems ( squint, optic atrophy , field defect ). Aggressive. Delinquent behavior. Depression.

24. Prognosis Prognosis of the children with hydrocephalus depends upon initiation of management and associated problem. Appropriate medical 7 neurosurgical treatment about 70% of these patient with infantile hydrocephalus. Live beyond first year of life. Without treatment mortality is as high as 50 to 60 %. Two thirds of the survived children has motor and intellectual handicapped condition. The long term follow up in a specialized setting may improve the prognosis.

25. SUMMARY A condition in which fluid accumulates in the brain, typically in young children renlarging the head & sometimes causing brain damage. Definition of hydrocephalus, CSF, circulation, type , etiology, incidence , clinical features, diagnostic evaluation, management, complication, prognosis of hydrocephalus.

26. BIBLIOGRAPHY