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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

slide2
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)
slide3
PREGNANCY & LABOUR…

Normal Pregnancy…up until… 33+4 / 40

…CTG: Fetal Distress (tachycardia)

ARM + Syntocinon

Vaginal Delivery

slide4
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)

slide5
HYDROCEPHALUS- DEF:

Disturbance of …FORMATION / FLOW /ABSORPTION …

of CSF   Volume occupied in the CNS.

slide6
HYDROCEPHALUS- DEF:

Disturbance of …FORMATION / FLOW /ABSORPTION …

of CSF   Volume occupied in the CNS.

FORMATION

FLOW

(indirectly inhibits absorption)

ABSORPTION

slide8
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:
slide9
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
slide10
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
slide11
SYMPTOMS… in Children:
  • Slowing of mental capacity
  • Headaches, Vomiting & Drowsiness
  • Neck pain
  • Blurred vision
  • Double vision
  • Difficulty in walking
slide14
SIGNS… in Children:
  • Papilledema
  • Failure of upward gaze
  • Macewen sign: "cracked pot“
  • Unsteady gait
  • Large head
  • Unilateral / bilateral 6th nerve palsy
slide15
INVESTIGATIONS:
  • ULTRASOUND (Evaluates intraventricular haemorrhage)
  • SKULL X RAY:
  • CT / MRI
slide16
INVESTIGATIONS:
  • ULTRASOUND (Evaluates intraventricular haemorrhage)
  • SKULL X RAY:
  • CT / MRI
slide17
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)
slide18
MANAGEMENT- Sx (SHUNT):
  • Establish communication between CSF and drainage cavity.
slide19
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.
slide20
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.
slide21
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’…
slide22
‘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
slide23
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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