Hydrocephalus 1/16/2015. Hydrocephalus. Functions of Cerebrospinal fluid (CSF) Flow of CSF

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1 Hydrocephalus Hydrocephalus Ruth Arms, MSN, CNS-BC, SCRN Hydrocephalus is the buildup of fluid in the cavities (ventricles) deep within the brain. The excess fluid increases the size of the ventricles and puts pressure on the brain. Cerebrospinal fluid (CSF) normally flows through the ventricles and bathes the brain and spinal column. Although hydrocephalus can occur at any age, it's more common among infants and older adults. Hydrocephalus affects about 1 out of every 500 children. Mayo clinic (2014) Functions of Cerebrospinal fluid (CSF) Keeping the brain buoyant, allowing the relatively heavy brain to float within the skull. Cushioning the brain to prevent injury. Removing waste products of the brain's metabolism. Flowing back and forth between the brain cavity and spinal column to maintain a constant pressure within the brain compensating for changes in blood pressure in the brain. Excess cerebrospinal fluid in the ventricles occurs for one of the following reasons: Obstruction. The most common problem is a partial obstruction of the normal flow of cerebrospinal fluid. Poor absorption. Less common is a problem with the mechanisms that enable the blood vessels to absorb cerebral spinal fluid. Overproduction. Rarely, the mechanisms for producing cerebrospinal fluid create more than normal and more quickly than it can be absorbed. Flow of CSF The ventricular system is made up of four ventricles connected by narrow passages. Normally, CSF flows through the ventricles, exits at the base of the brain, bathes the surfaces of the brain and spinal cord, and then reabsorbs into the bloodstream. Stoppler (2014) 1

2 Types of Hydrocephalus Types of Hydrocephalus Communicating hydrocephalus occurs when the flow of CSF is blocked after it exits the ventricles. Non-communicating hydrocephalus occurs when the flow of CSF is blocked along one or more of the narrow passages connecting the ventricles. Hydrocephalus ex-vacuo occurs when stroke or traumatic injury cause damage to the brain. Normal pressure hydrocephalus (NPH) can happen to people at any age, but it is most common among the elderly. Many people develop normal pressure hydrocephalus for reasons that are unknown. S/S of Hydrocephalus in Toddlers Physical symptoms Headache, Blurred or double vision Physical signs Abnormal enlargement of a toddler's head, Sleepiness, Difficulty remaining awake or waking up, Nausea or vomiting, Unstable balance, poor coordination, poor appetite, seizures Behavioral and cognitive changes Irritability, change in personality, problems with attention, decline in school performance, delays or problems with previously acquired skills, such as walking or talking S/S of Hydrocephalus in Older Adults Physical symptoms Loss of bladder control or a frequent urge to urinate Memory loss Progressive loss of other thinking or reasoning skills Difficulty walking, often described as a shuffling gait or the feeling of the feet being stuck Poor coordination or balance Slower than normal movements in general Diagnosis Neurological exam The type of neurological exam will depend on a person s age. Muscle condition Reflexes, muscle strength, muscle tone Sensory status Sense of touch, vision and eye movement, hearing Movement status Coordination, balance Psychiatric condition Mental status, mood Diagnosis Hydrocephalus is diagnosed through clinical neurological evaluation and by using cranial imaging techniques such as ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), or pressuremonitoring techniques. 2

3 Treatment Hydrocephalus is most often treated by surgically inserting a shunt system. One-third of all shunts fail within 1 year of placement. Patients with NPH often require multiple adjustments of opening pressure to optimize cognitive function and gait stability. Treatment Options Ventriculoperitoneal shunt (VPS) Third Ventriculostomy Lollis et al. (2010) Shunt Third ventriculostomy A shunt is a flexible but sturdy plastic tube. A shunt system consists of the shunt, a catheter, and a valve. A valve located along the catheter maintains one-way flow and regulates the rate of CSF flow. Codman (2014) A limited number of individuals can be treated with an alternative procedure called third ventriculostomy. Success in terms of this procedure is usually considered to be avoiding a shunt. Stoppler (2011) Management of Shunts: Overdraining or Underdraining Overdraining occurs when the shunt allows CSF to drain from the ventricles more quickly than it is produced. Underdraining occurs when CSF is not removed quickly enough and the symptoms of hydrocephalus recur. Complications Complications may include mechanical failure, infections, obstructions, and the need to lengthen or replace the catheter. Shunt systems require monitoring and regular medical follow up. When complications occur, the shunt system usually requires some type of revision. 3

4 Research A Case Study The National Institute of Neurological Disorders and Stroke (NINDS) and other institutes of the National Institutes of Health (NIH) conduct research related to hydrocephalus support additional research through grants to major medical institutions across the country. Much of this research focuses on finding better ways to prevent, treat, and ultimately cure hydrocephalus. Also, conducts and supports a wide range of fundamental studies that explore the complex mechanisms of normal and abnormal brain development. Stoppler (2011) MC had a subarachnoid hemorrhage due to a ruptured aneurysm. He subsequently needed a VPS for hydrocephalus. A Codman shunt was placed without complications and MC was discharged from the hospital. One month later, MC was admitted to the hospital for confusion and headache. It was determined that MC was underdraining and his shunt needed dialed down. His shunt is set at 100, we want to reprogram it to 50. When programming a shunt if you increase the number you are closing the valve further, if you decrease the number you are opening the valve more. MC s current setting: 100 After you adjust MC s shunt: 4

5 Second adjustment: Summary Many children and older adults have an active and fulfilling life while living with Hydrocephalus Questions? References Codman. (2014, December). Codman programmable shunt. Retrieved from CODMAN Programmable Shunt website: Lollis, S., Mamourian, A., Vaccaro, T., & Duhaime, A. (2010). Programmable csf shunt valves: Radiographic identification and interpretation. American Journal of NeuroRadiology. Retrieved from Mayo Clinic Staff. (2015, January). Hydrocephalus. Retrieved from Mayo Foundation for Medical Education and Research website: Stoppler, M. C. (2011). Hydrocephalus facts. Retrieved from MedicineNet.com website: 5

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