Hi. This is the lecture on pediatric hydrocephalus.
We're going to start by going over the definition of it and
the word hydrocephalus.
Then, we're gonna talk about some of the causes, the
manifestations of it,
and the major treatments for it.
Let's start with a definition or rather, the word.
Hydro and cephalus means water in the head or in the brain
in this case.
Basically, the definition is that it's a not normal
accumulation of CSF or cerebrospinal fluid in the brain.
You can see how the normal brain has ventricles that are
full of CSF.
Hydrocephalus on the right actually has expanded ventricles
which are putting pressure on the brain because they have
too much fluid in them.
This is actually a fairly common abnormality in newborns.
It occurs in about one to two out of every thousand infants.
Enlarged ventricles from the excess fluid causes the
ventricles to widen.
Then, they press on the brain. Pressing on the brain is
never a good thing.
It puts pressure on the tissues and that can keep the brain
from functioning properly.
It can also cause serious disability or death if not
All right. Let's review some of the major causes.
There are several congenital causes of hydrocephalus.
One of the first ones is neural tube defects.
The neural tube is basically the early brain and spinal cord
during fetal development.
When there's a defect in it, it can lead to hydrocephalus.
Arachnoid cysts are cysts or fluid-filled sacs that grow on
the brain and/or spinal cord.
That can also happen during fetal development and lead to
Dandy-Walker syndrome is a congenital brain malformation
that affects the cerebellum and the ventricle near it.
Arnold-Chiari Malformations are a group of deformities of
the posterior fossa
and the hind brain which is where most of the cranial nerves
And finally, congenital syphilis can cause congenital
because congenital syphilis can cause irritation and
inflammation of the fetal brain.
All right. Let's talk about some acquired causes for
And this is fairly intuitive, I think, because basically,
it's anything that can cause pressure,
bleeding, injury, or infection to the brain.
The brain just does not have a lot of tolerance for
And when they occur, more pressure can build up and more
fluid can build up or get blocked.
intracranial hemorrhages, meningitis, brain tumors, shunt
we'll talk about shunts in a moment, and just traumatic
brain injuries can all cause hydrocephalus.
All right. Let's review some of the common manifestations of
a child who has hydrocephalus.
In an infant, the first sign that may be noticed is an
enlarged head circumference.
Head circumferences should be taken at every routine
and also taken if a child comes in for an illness or injury
that may have affected the brain.
Early on, if a child has hydrocephalus, they may start
displaying subtle signs of illness
or altered mental status such as irritability,
not wanting to wake up or poor feeding is a really common
sign of serious illness
or injury in a young infant especially.
The frontal area of the head will eventually start
A term for this is called bossing.
The head would grow at an abnormal rate if the hydrocephalus
was not treated.
Eventually, it would be obvious and as this happens,
would increase within the brain.
A bulging fontanel may be present with or without an
The bulging fontanel results from the hydrocephalus that
causes that increased pressure in the brain.
Sometimes a fontanel is just slightly bulging or more tense.
Increased intracranial pressure might cause the eyes to
actually rotate down.
We call that a setting sun sign. It's more common in
infants, in young infants.
It looks as if they're trying to look at their lower
You see more of the white than you really should normally.
The pupils may also be sluggish and unequal in response to
The manifestations or signs and symptoms of hydrocephalus in
a child or infant
depends on several factors such as their age, the cause of
the location of the legion in the brain, and the degree of
increased intracranial pressure
that has resulted as well as any resulting brain damage.
All right. Let's review the major treatment for
Without treatment, death or permanent disability can occur.
The main treatment for hydrocephalus is a VP Shunt.
The long word for that is Ventriculoperitoneal Shunt
and that name is basically representative of how it goes
through the body
from the ventricles of the brain down to the peritoneum of
the abdomen or the peritoneal space.
Many people with shunts lead normal, healthy lives. These
shunts are internal.
They're inside the body. None of it is on the outside.
The only downside is that they may require some revisions
throughout life as the child grows.
Shunts can also get blocked and need to be surgically
repaired or replaced.
So anybody that has a VP Shunt and comes in to a hospital or
to a doctor's office,
or any kind of healthcare facility needs to be seen urgently
if they're having any kind of signs and symptoms that might
indicate a problem
with the shunt such as head pain or vomiting,
or other signs and symptoms of neurologic problems.
This is another type of drain, an external ventricular
That's a more short-term measure.
It's used in hospitals but nobody would go home with this.
Basically, it's a drain that's on the outside of the child.
So it would go from their ventricles where the excess fluid
and take some of the excess fluid out, would help drain it.
It would also help monitor the intracranial pressure,
so it provides monitoring and fluid drainage.
There's also a third type that's not a drain,
but actually, it's just a really quick way of monitoring
if somebody has hydrocephalus especially from a trauma, head
and if there's a need to see what their ICP actually is
inside their brain urgently
and that's called a bolt. That is sometimes put in by a
or intensivist in an emergency department at the bedside.
It's very dramatic. You may hear about it, so I just wanted
to mention that.
But the external ventricular drain and the
are the two major types of shunts used for hydrocephalus.
If hydrocephalus does not resolve by using an external
they may need to convert it to a VP Shunt.
Because again, you wouldn't go home with this but you can go
home with a VP Shunt
and many people live with them.
This is the NCSBN Clinical Judgement Measurement Model.
It's a framework being used in many next general NCLEX exam
questions and case studies.
You may hear about it in nursing school and you may see test
using it in your nursing school exams.
So we're going to relate some of the content in this lecture
to this model,
especially, the first two steps, recognizing cues and
In order to recognize and analyze cues of potential
hydrocephalus in an infant,
you must first be aware of how to recognize an abnormally
shaped head or an abnormally growing head.
You may need to know their baseline or their birth head
and compare it to any measurement you take.
The head circumference, the measurement,
and the procedure for how to do that is in our normal
newborn head lecture
but a quick review is basically you take a tape measure over
around the widest part of the head.
At birth, the average full-term head circumference is about
33 to 35 centimeters.
You should also be able to identify potential signs and
of hydrocephalus that are external and internal.
So in other words, if you see or feel a bulging fontanel,
that could be a sign of hydrocephalus.
If you see bossing or protrusion of the frontal area of the
head, that could be a sign of hydrocephalus.
And if there are clinical signs and symptoms that indicate
possible increased intracranial pressure,
it could be due to hydrocephalus.
Some of those in a neonate may be very subtle,
may include difficulty or refusal of feeding, irritability,
lethargy, or a weak cry.
Other signs in an older child might be a little more
May include vomiting, head pain, and some of the same other
signs, lethargy, irritability.
Also remember, in newborns and young infants,
they may show very - some subtle signs of intracranial
such as eye - eye deviation or the setting sun sign that
might indicate increased intracranial pressure.
The eye deviation or Nystagmus could be a sign of a seizure
which could also be a result from increased intracranial
Children of any age with increased intracranial pressure
could have a seizure if it goes on too far without being