Hydrocephalus

Background

• Caused by excessive cerebrospinal fluid accumulation, often from an obstructive process such as CSF shunt malfunction or subarachnoid hemorrhage
• Patients can also suffer from nonobstructive hydrocephalus due to excessive production of CSF

Clinical Features

Pediatric hydrocephalus with "sunset eyes."

• Headache
• Diplopia
• Ocular Palsy - 6th nerve palsy, strabismus
• Papilledema
• Nausea and Vomiting
• Altered Mental Status

Pediatric

In addition to above:

• Large fontanelles
• Dilated scalp veins
• "Cracked pot" sound on percussion
• Irritability
• Increased lower extremity tone
• Remember that Babinski sign is normal up to 3 years of age

Differential Diagnosis

Headache

Common

• Migraine headache
• Tension headache
• Cluster headache

Killers

• Meningitis/encephalitis
  • Neoplastic meningitis
• Myocardial ischemia
• Retropharyngeal abscess
• Intracranial Hemorrhage (ICH)
  • SAH / sentinel bleed
• Acute obstructive hydrocephalus
• Space occupying lesions
• CVA
• Carbon monoxide poisoning
• Basilar artery dissection
• Preeclampsia
• Cerebral venous thrombosis
• Hypertensive emergency
• Depression

Maimers

• Giant cell arteritis of temporal artery (temporal arteritis)
• Idiopathic intracranial hypertension (Pseudotumor Cerebri)
• Acute Glaucoma
• Acute sinusitis
• Cavernous sinus thrombosis or cerebral sinus thrombosis
• Carotid artery dissection

Others

• Trigeminal neuralgia
• TMJ pain
• Post-lumbar puncture headache
• Dehydration
• Analgesia abuse
• Various ocular and dental problems
• Herpes zoster ophthalmicus
• Herpes zoster oticus
• Cryptococcosis
• Febrile headache (e.g. pyelonephritis, nonspecific viral infection)
• Ophthalmoplegic migraine
• Superior Vena Cava Syndrome

Aseptic Meningitis

• Viral
  • Varicella
  • Herpes
  • Enterovirus
  • West Nile
• Tuberculosis
• Lyme disease
• Syphilis
• Leptospirosis
• Fungal (AIDS, transplant, chemotherapy, chronic steroid use)
• Noninfectious
  • Sarcoidosis
  • Vasculitis
  • Connective tissue disease
  • Drug induced aseptic meningitis

Evaluation

Typical hydrocephalus as seen on a brain CT. The lateral ventricles (black areas in the middle of the brain) are abnormally large and filled with fluid.

Obstructive hydrocephalus cause by a posterior fossa cyst in a 12 month old. Patient presented with loss of developmental milestones.

• Physical Exam to assess for papilledema or neuro defects
• CT Brain non contrast
  • In acute cases will see dilated ventricles and tight sulci
  • In chronic cases (loss of tissue with age, alcoholism, etc) will see dilated ventricles with large amount of CSF in sulci

See Also

• Normal pressure hydrocephalus
• Ventriculoperitoneal shunt obstruction