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HYDROCEPHALUS IN CHILDHOOD. WILL WESTON 4 TH Year Medical Student. BOBBY: 6 Year ♂. MOTHER’S PAST OBS HX…. 1989: 10 Year Old Girl (Term + NVD) 1991: 8 Year Old Boy (Term + NVD) 1993: 6 Year Old Boy (Term + NVD). PREGNANCY & LABOUR…. Normal Pregnancy…up until… 33+4 / 40

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Will weston 4 th year medical student

HYDROCEPHALUS

IN CHILDHOOD

WILL WESTON

4TH Year Medical Student


BOBBY: 6 Year ♂

MOTHER’S PAST OBS HX…

  • 1989: 10 Year Old Girl (Term + NVD)

  • 1991: 8 Year Old Boy (Term + NVD)

  • 1993: 6 Year Old Boy (Term + NVD)


PREGNANCY & LABOUR…

Normal Pregnancy…up until… 33+4 / 40

…CTG: Fetal Distress (tachycardia)

ARM + Syntocinon

Vaginal Delivery


AFTER LABOUR…

  • APGAR: 9 @ 1 min; 9 @ 5 mins.

  • ECG: Supraventricular Extrasystole  SCBU

  • Imaging: …

    Interuterine Fetal Intercranial bleeding

    (subarachnoid & interventricular haemorrhages)

    Hydrocephalus

    VP Shunt (10/3/00…aged 4/12)


HYDROCEPHALUS- DEF:

Disturbance of …FORMATION / FLOW /ABSORPTION …

of CSF   Volume occupied in the CNS.


HYDROCEPHALUS- DEF:

Disturbance of …FORMATION / FLOW /ABSORPTION …

of CSF   Volume occupied in the CNS.

FORMATION

FLOW

(indirectly inhibits absorption)

ABSORPTION


CAUSES:

CONGENITAL CAUSES IN INFANTS AND CHILDREN:

  • Stenoses of aqueduct of Sylvius due to malformation (10%):

  • Others:

    • Dandy-Walker malformation

    • Arnold-Chiari malformation type 1 and type 2

    • Agenesis of the foramen of Monro

    • Congenital toxoplasmosis

    • Bickers-Adams syndrome:


CAUSES:

ACQUIRED CAUSES IN INFANTS AND CHILDREN

  • Mass lesions: 20%

  • Intraventricular haemorrhage

  • Infections: Meningitis (especially bacterial).

  • Increased venous sinus pressure

  • Iatrogenic: E.g. Hypervitaminosis A

  • Idiopathic


SYMPTOMS… in Infants:

  • Poor feeding & Activity

  • Irritability & Vomiting

SIGNS… in Infants:

  • Head enlargement

  • Dysjunction of sutures & Tense fontanelle

  • Dilated scalp veins

  • Setting-sun sign: Characteristic in infants of  ICP.

  • Increased limb tone


SYMPTOMS… in Children:

  • Slowing of mental capacity

  • Headaches, Vomiting & Drowsiness

  • Neck pain

  • Blurred vision

  • Double vision

  • Difficulty in walking



SIGNS… in Children:

  • Papilledema

  • Failure of upward gaze

  • Macewen sign: "cracked pot“

  • Unsteady gait

  • Large head

  • Unilateral / bilateral 6th nerve palsy


INVESTIGATIONS:

  • ULTRASOUND (Evaluates intraventricular haemorrhage)

  • SKULL X RAY:

  • CT / MRI


INVESTIGATIONS:

  • ULTRASOUND (Evaluates intraventricular haemorrhage)

  • SKULL X RAY:

  • CT / MRI


MANAGEMENT- MEDICAL:

  • Used to delay surgical intervention.

  • May be tried in premature infants with posthemorrhagic hydrocephalus.

    •  CSF Secretion by choroid plexus

      • Acetazolamide & Furosemide

  •  CSF Reabsorption

    • Isosorbide (effectiveness is questionable)


MANAGEMENT- Sx (SHUNT):

  • Establish communication between CSF and drainage cavity.


  • VENTRICULO-PERITONEAL (VP).

    • Lateral ventricle  Peritoneum.

    • Advantage: No need to lengthen catheter with growth.

  • VENTRICULO-ATRIAL (VA)

    • Cerebral ventricles  Jugular Vein  SVC  RA.

    • Used when patient has abdominal abnormalities

  • Others:

    • Lumboperitoneal / Torkildsen / Ventriculopleural.


MANAGEMENT- Sx (Others):

  • Ventricular tap

  • Open ventricular drainage

  • LP in Posthemorrhagic & Postmeningitic hydrocephalus.

PROGNOSIS:

  • Long-term outcome related directly to cause of hydrocephalus.

    • Up to 50% with large intraventricular haemorrhage  Permanent hydrocephalus requiring shunt.


SINCE LABOUR…

Drug Hx:

  • No Known Allergies

  • All Relevant Immunisations

  • Movicol: Constipation

  • PMHx:

    • Occasional blocking of shunt, but currently satisfactory.

    • Asperger’s Syndrome (Special Ed at mainstream school)

    • Headaches

    • ‘Trance like episodes’…


  • ‘TRANCE LIKE EPISODES’…

    Timing:

    • Occur in clusters (weeks - months apart) > often at school.

    • Frequency of Clusters: 2-3 / Episodes a week.

    • Duration of each episode lasting secs – mins.

      Observations:

    • Staring blankly

    • Tachypnoea

    • Lasting


    MANAGEMENT PLAN…

    • School Diary

    • Video Footage: Parents & Teachers’ Mobile Phones

    • EEG

      • Mental retardation, Cerebral palsy and EPILEPSY are known to be related to infantile hydrocephalus1,2

  • Persson EK, Hagberg G, Uvebrant P. Hydrocephalus prevalence and outcome in a population-based cohort of children born in 1989-1998. Acta Pædiatrica; 2005 Jun;94(6):726-32.

  • Battaglia D et al. Epilepsy in shunted posthemorrhagic infantile hydrocephalus owing to pre- or perinatal intra- or periventricular hemorrhage. J Child Neurol. 2005 Mar; 20 (3):219-25.



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