HYDROCEPHALUS

The diagnosis of hydrocephalus seems strange and threatening to most patients and their families, but it is a common condition. Probably as many as 2 or 3 newborns in a thousand are born with hydrocephalus, either as an isolated problem or as a part of a more complicated collection of birth defects. Eventually it finds its way out of the brain and the skull, where it is reabsorbed or recycled back into the blood stream. These processes of production and recycling go on continuously inside all of us at a rate of 1 pint of CSF per day.

Hydrocephalus is an excess of cerebrospinal fluid (CSF) in the ventricles or the subarachnoid space. In the infant whose cranial sutures are not firmly knitted, this excess fluid causes enlargement of the skull. This may cause increased intracranial pressure inside the skull and progressive enlargement of the head, convulsion, tunnel vision, and mental disability. Hydrocephalus can also cause death. Normally, this fluid cushions your brain. When you have too much, though, it puts harmful pressure on your brain. The term hydrocephalus is derived from the Greek words "hydro" meaning water and "kephalos" meaning head. CSF has three important life-sustaining functions: to keep the brain tissue buoyant, acting as a cushion or "shock absorber"; to act as the vehicle for delivering nutrients to the brain and removing waste; and to flow between the cranium and spine and compensate for changes in intracranial blood volume (the amount of blood within the brain). The balance between production and absorption of CSF is critically important. Because CSF is made continuously, medical conditions that block its normal flow or absorption will result in an over-accumulation of CSF. The resulting pressure of the fluid against brain tissue is what causes hydrocephalus. People with hydrocephalus have a problem with the balance between production and recycling of CSF. Production of CSF goes on at a constant rate regardless of other circumstances within the body or in the environment as long as life lasts, but the recycling of CSF depends on pressure within the head: The higher the pressure, the more rapidly CSF is recycled. Normal pressures in the head range between 15mmHg lying down and subatmospheric levels standing up. In most

of us these pressures drive enough CSF back into the bloodstream to maintain a balance with CSF production. In people with hydrocephalus, however, flow of CSF between the ventricles and recycling of CSF are impaired, and higher than normal pressures within the ventricles are necessary to keep production and recycling in balance.

What causes Hydrocephalus?

The causes of hydrocephalus are still not well understood. Hydrocephalus may result from inherited genetic abnormalities (such as the genetic defect that causes aqueductal stenosis) or developmental disorders (such as those associated with neural tube defects including spina bifida and encephalocele). Other possible causes include complications of premature birth such as intraventricular hemorrhage, diseases such as meningitis, tumors, traumatic head injury, or subarachnoid hemorrhage, which block the exit of CSF from the ventricles to the cisterns or eliminate the passageway for CSF into the cisterns. During infancy, hydrocephalus is usually a major developmental defect. From birth to 2 years of age most cases are the result of the Arnold-Chiari malformation, aqueduct stenosis, and a glial tumor of the aqueduct. Hydrocephalus is so often associated with meningomyocele that all such infants should be observed for its development. In the remainder of these cases there is a history of intrauterine infection, perinatal hemorrhage and neonatal meningocephalitis. In other children, hydrocephalus is most often the result of space-occupying lesions, pre-existing developmental defects, intracranial infections or hemorrhage.

Types of Hydrocephalus
There are two types of hydrocephalus: communicating and noncommunicating. In communicating hydrocephalus, there is an obstruction outside the ventricular system causing decreased absorption of cerebrospinal fluid in the subarachnoid space at the subarachnoid villi. Noncommunicating or obstructive hydrocephalus, which is responsible for 99% of al occurrences in children, is caused by an impediment of cerebrospinal fluid flow within the ventricular system. Most often, this is secondary to congenital malformation such as aqueductal stenosis, meningomyocele, Dandy-Walker syndrome or Arnold-Chiari malformation.

Pathophysiology
1. The primary site of CSF formation is believed to be the choroid plexus of the lateral ventricles. CSF flows from the lateral ventricles through the foramen of Monro to the third ventricle, then through the aqueduct of Sylvius into the fourth ventricle through the foramen of Luschka and the midline foramen of Magendie into the cisterna magna. From there it flows to the cerebral and cerebellar subarachnoid spaces where ti is absorbed. 2. Causes of Hydrocephalus are varied but result in either impaired absorption of CSF within the arachnoid space (formerly referred to as communicating hydrocephalus) or obstruction to the flow of CSF through the ventricular system (formerly referred as noncommunicating hydrocephalus. 3. Most cases of obstruction are the result of developmental malformations; other causes include neoplasms, infection and trauma. Obstruction to the normal flow can occur at any point in the CSF pathway, which produces increased pressure and dilation of the pathways proximal to the site of obstruction. 4. Impaired absorption can result form meningitis, prenatal maternal infections, meningeal malignancy (secondary to leukemia or lymphoma), an arachnoid cyst, and tuberculosis.

Signs and Symptoms

> Blurred or double vision > Cognitive difficulties > Downward gaze or "sun-setting eyes > Imbalance and dizziness > Incontinence > Irregular gait > Lethargy > Nausea and vomiting > Weakness > Headache

High pressure within the head and the distention of the ventricular system that usually accompanies it cause a variety of symptoms depending on age, rapidity of onset, and severity. In infancy hydrocephalus manifests itself most characteristically by of accelerated head growth. The infants soft spot, or fontanel, may be convex and tense, and in severe cases there may be irritability, vomiting, lethargy, and coma. If the symptoms are neglected or misinterpreted, hydrocephalus can be life-threatening. Later in childhood and in adult life, the rigidity of the skull may cause symptoms to progress more rapidly, but on the other hand, greater self-awareness in older children and adults may bring them to attention earlier with symptoms of headache, mental dullness, or anorexia.

The rigid skull of older patients in some cases allows pressure to rise to levels that affect vision as well. The abnormal pressure can cause swelling of the optic nerves, which are the large nerves that convey visual information from the eyes to the brain. This swelling is called papilledema, and physicians can actually see papilledema by examining the eyes carefully. Severe, long lasting hydrocephalus can cause blindness.

The classical clinical picture of normal pressure hydrocephalus includes urinary incontinence and a distinctive pattern of gait disturbance, but these associated symptoms are of variable prominence from case to case.

Diagnostic Tests
Magnetic resonance imaging (MRI) or computer tomography studies reveal significantly increased CSF in the ventricles of the brain and decreased CSF in the medial subarachnoid spaces as compared with individuals with Alzheimer's disease or vascular dementia. Other radiologic and imaging examinations may also be utilized. Ultrasound or echoencephalography, used exclusively in the neonate because of the open fontanelle, will show disproportionaly large lateral and third ventricles.

Test

Description
Flashlight with a rubber adapter is held snugly against the infants head in a totally darkened room

TRANSILLUMINATION

CSF EXAMINATION

Ventricular or spinal tap

RADIOGRAPHY

Anteroposterior and lateral skull films

COMPUTERIZED AXIAL TOMOGRAPHY

Pinpoint X-ray beam is directed on a horizontal or vertical plane to provide a series longitudinal cuts that are fed into the computer, assembled in an image displayed on a videoscreen, and transferred to a permanent record

AIR ENCEPHALOGRAPHY

X-ray visualization of ventricular system and subarachnoid spaces after injection of air or oxygen into the CSF pathways

DYE

Contrast medium is introduced into the lateral ventricles via ventricular puncture

BRAIN SCAN

Isotope scan for gamma emission follows injection of radioordinated human serum albumin into the lumbar or cisternal subarachnoid space

THERAPEUTIC MANAGEMENT
The most common approach to treatment of hydrocephalus is to give the CSF somewhere else to go where it can be recycled at low pressure. The treatment for hydrocephalus is exclusively surgical. Medical therapy directed toward reduction of the production of the cerebrospinal fluid has proved to be ineffective at all.

A CSF SHUNT is inserted by means of an operation. The ventricular segment of the shunt enters the head through a small hole in the skull, and the downstream segment proceeds to its destination under the skin. No part of it lies outside the body. The shunt includes a resistance element called a valve, which is intended to regulate how rapidly CSF drains through the system, and most shunt designs also include a bubble or reservoir that can be punctured with a needle for diagnostic purposes. The shunt can be felt, if one knows where to look for it, but i t usually cant be seen. Most CSF shunt designs include a pumping mechanism for moving CSF through the shunt. Compression of the bubble reservoir expels CSF out of the valve downstream, and as the bubble relaxes, it sucks CSF into the valve from upstream.

Other types of shunting system: LUMBOPERITONEAL - diverts cerebrospinal fluid from the lumbar subarachnoid space to the peritoneum VENTRICULAR PLURAL diverts CSF to pleural cavity VENTRICULAR BYPASS intracranial channels are recreated

Nursing Diagnosis
Pre operatively:

1. Risk for injury to neck muscles related to enlarged head and large, heavy cranial vault 2. Risk for impaired skin integrity related to thin skin 3. Imbalanced nutrition: less than body requirements related to potential for vomiting and need for proper positioning when feeding 4. Excess fluid volume related to alteration in CSF flow 5. Decrease intracranial adaptive capacity related to alteration in CSF flow 6. Potential for injury related to increase intracranial pressure 7. Altered family process related to child with chronic defect

Postoperatively:

1. 2. 3. 4. 5.

Risk for imbalanced fluid volume related to cerebrospinal fluid draining too quickly Risk for excessive fluid volume related to surgery Risk for impaired skin integrity related to thin skin Risk for infection related to surgical site Decrease intracranial adaptive capacity related to alteration in CSF flow prior to surgery

Nursing Management
ASSESSMENT o Obtain clients baseline information o Obtain diagnostic and laboratory tests results o Do a physical assessment (cephalocaudal)

INTERVENTION Monitor patients temperature. -fever may reflect damage to hypothalamus Do tepid sponge bath in the presence of fever -increased metabolic needs and oxygen consumption occur (especially with fever and shivering), which can result to further increase intracranial pressure Monitor intake and output, weigh as indicated. Note skin turgor, status and mucus membrane -useful indicators of body water, which is an integral part of tissue perfusion Maintain head and neck midline or in neutral position, support with small towel rolls and pillows. Avoid placing large pillows -turning head to one side compresses the jugular veins and inhibits cerebral venous drainage that may cause increased intracranial pressure Provide rest and periods care of activities and limit duration of procedures -continual activity can increase intracranial pressure by producing a stimulant effect Lessen extraneous stimuli and provide comfort measures such as back massage, quiet environment, gentle touch. -provide calming effect reduces adverse physiological response and promotes rest Help patient avoid or limit coughing, crying, vomiting and straining a stool. Reposition the patient slowly. -these activities increase intrathoracic and abdominal pressure Elevate the head gradually 15-30 degrees as tolerated or indicated. -promotes venous drainage from head, reducing cerebral congestion and edema and intracranial pressure

References

Bracke, M., Taylor and Kinney, A.B.: External Drainage of Cerebrospinal fluid, Am. J. Nurs. 78: 1355-1358, 1978 Conway, B.L.: Pediatric neurologic nursing, St. Louis, 1977, The C.V. Mosby Co. Pilliterri, Adele. Maternal and child health nursing : care of the childbearing and childrearing family/Adele Pilliterri. 6th edition

www.nursingcrib.com www.scribd.com www.healthpost.com

Notre Dame University College of Health Sciences Cotabato City

CASE BOOK REPORT ON

Submitted by: CORDOVA, Mary Jeargs Claire B. ETIC, Joanna Rose F.

Submitted to: Maam Joyce Bisnar, RM, RN

Date Submitted: February 3, 2012