Hydrocephalus

Hydrocephalus

• The disease known as hydrocephalus is defined by an excessive buildup of fluid in the brain.
• Is the state of an imbalance between the synthesis of CSF and its absorption into the circulatory system across the surface of the brain?
• Both congenital and acquired hydrocephalus are possible.
• The term "hydrocephalus" refers to an abnormal buildup of cerebrospinal fluid in the intracranial spaces, which is characterized by cerebral ventricle enlargement and elevated cerebrospinal fluid pressure. It happens when there is an increase in CSF fluid production or a decrease in its absorption.

Cerebrospinal fluid(CSF) circulation pathways
The choroids plexus of the cerebral ventricles (lateral, third, and fourth) secretes cerebrospinal fluid by an active transport process that travels over the endothelium of capillaries in the choroids plexus' villous process. Then it moves toward the basal cisterns and subarachnoid spaces, which are lateral to the third and third to fourth ventricles. Here, the CSF enters the venous channel and sinuses through the arachnoids' villi.

Causes of hydrocephalus

Hydrocephalus may be congenital or acquired.

Congenital causes

• Infection within the uterus ( rubella, cytomegalovirus)
• Internal bleeding and congenital brain tumor
• Birth defect such as aqueduct stenos ( most common causes for hydrocephalus)
• Arnold-Chiari syndrome and the Dany Walker syndrome

Acquired causes

• Inflammation/ infection
• Neoplasm
• Chemical- hypervitaminosis i.e. Vitamin A and ruptured aneurysm, trauma to the head, intraventricular hemorrhage etc.

Types

Hydrocephalus is classified into two classes:

• Communicating type 
  Is the most prevalent kind of hydrocephalus in kids. The ventricular system is patent, but the basal subarachnoid cisterns and subarachnoid sulci are blocked. The most prevalent cause of pediatric hydrocephalus of this type is meningitis.
• Non- communicating type
  Congenital conditions frequently involve CSF route obstruction at or close to the fourth ventricle's outlet foramina.

Pathophysiology

Assuming aqueduct stenosis is a contributing factor, it prevents the CSF from moving along its regular channels. This causes the ventricles to enlarge and disrupts the ependymal lining of the ventricles. There will be subependymal edema and peri-ventricular oozing, which will compress the white matter. The manifestation of hydrocephalus symptoms and signs is caused by compression of white matter.

Sign and symptoms

Age at disease onset, disease duration, and disease severity can affect signs and symptoms. Nearly 50% of children with early onset (0–2 years) may not have any symptoms. Vomiting, sleepiness, failure to thrive, harsh cries, and delayed motor milestones can all be signs of an asymptomatic infant. Other characteristics include an abnormal or progressive increase in head size, an overshadowed face, frontal bossing, triangular faces, a shiny, tense scalp with few hairs, open anterior fontanels, a sunset-colored eye, ptosis, nystagmus, and spasticity of the lower limbs, among others.

Papilledema, headaches, and vomiting are frequent symptoms of late onset (2–10 years). Crackpot resonance noises on percussion of the skull during examination will also reveal personality and behavioral abnormalities.

Diagnosis

• Presentations featuring kids
• The daily head circumference is accurately serially recorded as part of the physical checkup.
• Impression: Hydrocephalus should be suspected if a baby's head circumference increases by more than 1 cm per 15 days during the first three months of life.
• For older children, a CT scan or MRI with or without contrast will be used to evaluate the severity and underlying causes of the condition. USG of the ventricle is helpful for newborns.
• X-ray of a skull

Management

Management includes:

Medical management + surgical management + nursing management

Medical management

To lower intracranial pressure, patients are given either the medication acetazolamide (Diamox) 50 mg/kg/d or oral glycerol. But these medications could give the newborn electrolytemia in a matter of days. Therefore, it is helpful for children who present later than expected and have both mild and severe hydrocephalus (older than 6 months). Careful follow-up is necessary for medical management in order to evaluate the ventriculomegaly, mental and cognitive development, as well as fundus changes.

Surgical management

• Ventriculostomy, choroid plexectomy
• Surgical shunt: Ventriculo- peritoneal shunts i.e. V-P shunt.
• The ventriculoatrial shunt, ventriculo- pleural shunt, or ventriculo- gallbladder shunt are additional methods.

Nursing management

Nursing management will be started from;

• The assessment of the child includes daily measurements of the head circumference in centimeters, the fontanel status, the child's level of consciousness, pupillary response, vital signs, breathing patterns, signs of increased intracranial pressure, skin breakdown, incontinence of the bladder and bowel, neurological deficit, motor activity, change in feeling, and behavior, among other things.
• Nursing intervention
• Maintain cerebral perfusion
• Avoid raising intracranial pressure by administering medications, maintaining intake output, and positioning the infant's head correctly.
• Ensuring that infants up to the age of six months receive adequate nutrition by exclusively breastfeeding, providing small, frequent feedings, and putting the infant in a semi-sitting position with their heads raised during and after each feeding.
• Provide pre- operative care if surgery is indicated
• Post-operative care
• Intake and output are carefully monitored
• Put child on NPO for 24- 48 hours
• To prevent pressure on the shunt, carefully position on the side that wasn't operated, and take care of your skin as necessary.
• Kept flat to prevent subdural hematoma unless there is increased intracranial pressure
• Assess for pupillary dilation
• Measure vital signs frequently and keep an eye out for signs of elevated ICP, which indicate shunt obstruction. Examine the surgical site for leakage or soakage
• Prevention of infection: Administer of antibiotics, proper wound care under aseptic environment
• Family counseling and support during hospitalization
• Parents' instruction before discharge covers shunt care, feeding, signs of elevated intracranial pressure, positioning of the child after the shunt (for example, initially flat to prevent excessive CSF drainage, then gradually elevated up to 30-400), and assessing for signs of excessive CSF drainage (for example, sunken fontanels, agitation, decreased level of consciousness, and home care of the child, medication, and follow-up visit).