What is Hydrocephalus
Hydrocephalus is the accumulation of cerebrospinal fluid (CSF or cerebrospinal fluid) in the cranial ventricular cavities, causing an increase in intracranial pressure on the brain, which can cause lesions in the brain tissue, as well as enlargement and swelling of the skull.
The cerebrospinal fluid is a fluid that bathes the brain and spinal cord in order to avoid any trauma or shock to the central nervous system. It is produced and absorbed by the ventricles located in the person’s skull, through the bloodstream, however, when there are obstructions in the small holes through which it circulates, the process can be hampered.
In addition to this function of protecting the brain and spinal cord, the CSF has two other features:
- It acts as a vehicle to supply nutrients to the brain and also remove waste from it;
- Compensate for changes in intracranial blood volume between the skull and spine.
Regarding epidemiology, hydrocephalus affects around 1 to 3 people for every 1000 births. In addition, 60% of cases affect newborns and 40%, the elderly, the male group being more likely to develop.
Hydrocephalus can be classified into 3 different types and, for that, it will depend on its cause. Condition classifications are:
- Obstructive (non-communicating): when there is a block that prevents the CSF from flowing normally;
- Non-obstructive (communicating): it is the result of the excessive increase of the CSF (rare cases) or, still, of the decrease of the capacity of the blood vessels to absorb the CSF;
- Normal pressure (communicating): it is a type of hydrocephalus that affects adults, especially the elderly, and, often, intracranial pressure does not increase, even if CSF levels are high. It may be the result of trauma or illness, but the concrete causes of this type are not yet known.
Obstructed CSF flow can be caused by the following situations:
- The obstruction of the foramen of Monro can lead to the dilation of one or both lateral ventricles;
- The Sylvius Aqueduct (cerebral aqueduct) can be obstructed by several genetically acquired lesions (such as hemorrhages and tumors), leading to the dilation of both lateral ventricles, as well as the third ventricle;
- When the fourth ventricle is obstructed, it leads to dilation of the lateral ventricles and also the third;
- The foramina of Luschka and Magendie can be obstructed due to a congenital opening failure.
Caused by CSF reabsorption without any obstruction between the fluid flow and the cranial ventricles, this hydrocephalus can be caused by:
- Central nervous system infections, such as meningitis;
- Cerebral hemorrhage during or shortly after delivery, especially in premature babies;
- Injuries that occur before, during or after childbirth;
- Head trauma;
- Tumors located in the central nervous system.
The cause of this is usually something that prevents the proper flow of CSF into the bloodstream. You are more likely to develop it if you have experienced any of these situations:
- Brain infections, such as meningitis;
- Head injuries;
- Bleeding from a blood vessel in your brain;
- Brain surgery.
As hydrocephalus can happen to anyone and at any age – the symptoms vary according to the patient’s age group.
Symptoms in Babies
The most common symptoms of the condition in babies are:
Change in the head
- An unusual and rapid increase in the head;
- A more prominent spot on the top of the head (fontanelle or soft spot).
- Deficiency in food;
- Eye shrinkage (stare downwards);
- Deficits in muscle tone and strength, as well as in their expected growth.
Symptoms in young children and older children
In this age group, the most common symptoms are:
- Blurry or double vision.
- Abnormal enlargement of the head;
- Difficulty waking up or staying awake;
- Nausea or vomiting;
- Unstable balance;
- Poor coordination;
- Little appetite;
Cognitive and behavioral changes
- Change in personality;
- Attention problems;
- Decline in school performance;
- Delays or problems with previously acquired skills, such as speaking or walking.
Symptoms in young and middle-aged adults
The most recurrent symptoms at this stage are:
- Difficulty waking up or staying awake;
- Loss of coordination and balance;
- Urinary incontinence;
- Impaired vision;
- Deficit in attention, concentration and other skills that involve thinking.
Symptoms in the elderly
Among adults over 60 years of age, the symptoms that characterize hydrocephalus are:
- Urinary incontinence;
- Loss of memory and other skills related to thinking or reasoning;
- Difficulty walking (dragging or feeling your feet are stuck);
- Poor coordination or balance;
- Slow movement.
It is necessary to be aware of these symptoms, because, in this age group, hydrocephalus is confused with other disorders, such as Parkinson’s disease and Alzheimer’s disease.
In most cases, the exact cause for the development of the condition is not known. However, what is known is that some environmental or medical events can contribute to the emergence of hydrocephalus.
- Abnormal development of the central nervous system, which can obstruct the flow of CSF;
- Incomplete closure of the neural tube, also known as spina bifida;
- Hemorrhage within the ventricles, possible complication of premature delivery;
- Infection in the uterus during pregnancy, such as rubella or syphilis.
- Injuries or tumors in the brain or spinal cord;
- Central nervous system infections, such as bacterial meningitis or mumps;
- Bleeding in the brain due to a stroke or head injury;
- Other traumatic brain injuries.
The diagnosis for hydrocephalus is divided into two types and both are performed by the neurologist. First, a clinical neurological exam is performed and, after them, brain imaging exams are requested.
Better understand each one:
As each age group has different symptoms of the disease, this neurological examination will also be different for each one of them. In addition to questions, the doctor will do simple tests in the office, such as:
- Muscle conditions : as reflexes; muscle strength and tone.
- Sensory state : as a sense of touch; vision and eye movement; hearing;
- Movement status : as coordination; balance;
- Psychiatric condition : as a mental state; humor.
If the specialist continues to suspect hydrocephalus even after these clinical tests, brain imaging tests may be ordered. They are:
Exam that evaluates the size of the ventricles and other brain structures.
Evaluates Chiari malformation (a condition in which the brain tissue extends into the spinal canal) or cerebellar or periaqueductal tumors.
Ultrasonography in infants
This test is necessary to see if there is any intraventricular hemorrhage. In addition, it also checks for possible progressive hydrocephalus.
Detects possible erosions on the skull, such as that of the Turkish saddle.
Measures the volume of cerebrospinal fluid in the cerebral aqueduct.
Diffusion tensor image
Examination that allows the recognition of microstructural changes in the white matter region (set of cells that have the function of supporting, sustaining, electrically isolating or nourishing neurons and ganglia).
As hydrocephalus does not have a permanent cure, the treatments available for the condition serve to control it. Usually, these treatments are accompanied by a neurologist and must be done as soon as possible, so that sequelae can be avoided.
It is estimated that 140,000 people undergo hydrocephalus treatment every year, which can be in the following ways:
Ventricle-Peritoneal Bypass (DVP)
It consists of implanting a valve, through surgery, that will drain the CSF into the peritoneum (abdominal cavity) or the heart (right atrium), since the brain is unable to perform the function. As this procedure can have consequences such as catheter obstruction or infections, Professor Maurice Choux, from the city of Marseille (France), recommends that these surgeries be the first in the morning and that no more than three surgeries of the type be carried out in a single day. .
Neuroendoscopy is performed by introducing a very thin device (endoscope) through a hole made in the skull. Once this is done, the endoscope navigates through the cerebral ventricles and, with the opening of the third ventricle floor, the CSF can circulate normally between the ventricular system and the subarachnoid space.
Currently more advanced technique, through ultrasound it is already possible to detect the disease in the baby, from the 16th week of gestation, and, in the 24th week, surgery on the fetus can be performed, still inside the mother’s belly. Through this surgery, doctors perform punctures in the baby’s ventricle to remove the excess CSF or install a catheter that diverts it into the amniotic fluid. With the birth of the child, this catheter is removed, replacing it with the bypass system.
This type of treatment is only indicated in cases that are not caused by chromosomal changes or infectious diseases.
Some medications can be used to reduce CSF production, such as Acetazolamide or Furosemide . It is important to note that its use is not effective in the long term, but serves to temporarily postpone a surgical procedure.
NEVER self-medicate or stop using a medication without first consulting a doctor. Only he will be able to tell which medication, dosage and duration of treatment is the most suitable for his specific case. The information contained on this site is only intended to inform, not in any way intended to replace the guidance of a specialist or serve as a recommendation for any type of treatment. Always follow the instructions on the package insert and, if symptoms persist, seek medical or pharmaceutical advice.
When not properly treated, hydrocephalus can cause the patient to die, usually due to a secondary tonsillar hernia. In addition, as already mentioned, complications of PVD can arise, in addition to the consequences that the disease brings to the patient’s health.
Consequences of DVP
Placing the valve on a patient suffering from hydrocephalus can cause several complications, which can be divided into mechanical and biological:
- Mechanical complications: related to catheter obstruction, valve obstruction or rupture of the material from which it is made;
- Biological complications : the most frequent complications of this type are infections, which can lead to meningitis, ventriculitis, peritonitis or endocarditis.
Regarding infections, according to the literature, the incidence is higher in the first year after the valve is placed, it varies between 0.5 to 15% chance. Regarding the functioning of the device, it is estimated that 30% of those that were implanted stop working in the first year.
In addition, some of these complications can lead to other problems, such as excessive CSF drainage or under-drainage:
- Excess drainage: occurs when the valve allows CSF to drain from the ventricles faster than it is produced. This causes the ventricles to collapse, tearing the blood vessels and causing headache, bleeding and slit ventricles.
- Sub-drainage: in this case, the CSF is not absorbed quickly and causes the symptoms of hydrocephalus to reappear.
Consequences of hydrocephalus
The sooner it is diagnosed, the better the treatment for hydrocephalus will be. This is due to the fact that, when not treated properly, the condition can lead to sequelae when brain tissue is severely affected. Among these sequels, there may be:
- Problems in mental and / or motor development;
- Difficulties in learning and reasoning;
- Speech difficulties;
- Difficulties in walking.
When the case is very severe, hydrocephalus can also cause irreparable damage to the brain, such as mental retardation or paralysis, as well as death. In addition, one patient in four develops epilepsy due to the condition.
It is known that eye problems can also occur, since the increase in intracranial pressure in the patient is transmitted to the optic nerves, which can cause edema of the optic papilla. When hydrocephalus is not properly treated, this edema may develop into blindness. Therefore, at the signal of any change in vision, the ideal is to seek medical help from an ophthalmologist.
It must be kept in mind that patients suffering from hydrocephalus may have difficulties in cognitive and physical development. However, many of them benefit from therapies performed by an interdisciplinary team, composed of doctors, specialists in rehabilitation and education.
- Pediatrician or physiatrist: supervises the treatment and medical care plan;
- Pediatric neurologist: doctor specializing in the diagnosis of brain disorders in children;
- Occupational therapist: develops therapies that will assist in the development of everyday skills;
- Developmental therapist: helps the child to develop behaviors consistent with his / her age, in addition to social and interpersonal skills;
- Psychologist or psychiatrist: checks the patient’s mental health;
- Social worker: helps the family with the lived reality;
- Special education teacher: addresses learning difficulties, determines education needs and identifies the most appropriate educational resources.
As adults can have more severe complications, they need the help of the following specialists:
- Occupational therapist;
- Social worker;
- Specialist in dementia care, due to memory loss and other functions that are related to thinking.
Hydrocephalus cannot be prevented, but some precautions can help prevent the condition from developing.
Prenatal care in pregnancy
Taking proper care during pregnancy reduces the chance of premature labor , which can cause hydrocephalus.
Infectious diseases that can cause hydrocephalus must be prevented through vaccination.
Use of safety equipment
Prevent head injuries from occurring, so always use safety equipment, such as helmets and seat belts. Also, make sure the car seat is properly installed, as it can also prevent injuries to the baby’s head from happening.
As hydrocephalus is a condition that can affect people of any age, it is important to be aware of the signs that it can cause. Share this article with your friends and acquaintances and let the information here reach more people!