What is hydrocephalus?

The term hydrocephalus is derived Irom the Greek words "hydro" meaning water and "cephalus"
meaning head. As the name implies, it is a condition in which the primary characteristic is
excessive accumulation oI Iluid in the brain. Although hydrocephalus was once known as "water
on the brain," the "water" is actually cerebrospinal Iluid (CSF)--a clear Iluid that surrounds the
brain and spinal cord. The excessive accumulation oI CSF results in an abnormal widening oI
spaces in the brain called ventricles. This widening creates potentially harmIul pressure on the
tissues oI the brain.
The ventricular system is made up oI Iour ventricles connected by narrow passages.. Normally,
CSF Ilows through the ventricles, exits into cisterns (closed spaces that serve as reservoirs) at the
base oI the brain, bathes the surIaces oI the brain and spinal cord, and then reabsorbs into the
bloodstream.
CSF has three important liIe-sustaining Iunctions: 1) to keep the brain tissue buoyant, acting as a
cushion or "shock absorber"; 2) to act as the vehicle Ior delivering nutrients to the brain and
removing waste; and 3) to Ilow between the cranium and spine and compensate Ior changes in
intracranial blood volume (the amount oI blood within the brain).
The balance between production and absorption oI CSF is critically important. Because CSF is
made continuously, medical conditions that block its normal Ilow or absorption will result in an
over-accumulation oI CSF. The resulting pressure oI the Iluid against brain tissue is what causes
hydrocephalus.
What are the different types of hydrocephalus?
Hydrocephalus may be congenital or acquired. Congenital hydrocephalus is present at birth and
may be caused by either events or inIluences that occur during Ietal development, or genetic
abnormalities. Acquired hydrocephalus develops at the time oI birth or at some point aIterward.
This type oI hydrocephalus can aIIect individuals oI all ages and may be caused by injury or
disease.
Hydrocephalus may also be communicating or non-communicating. Communicating
hydrocephalus occurs when the Ilow oI CSF is blocked aIter it exits the ventricles. This Iorm is
called communicating because the CSF can still Ilow between the ventricles, which remain open.
Non-communicating hydrocephalus - also called "obstructive" hydrocephalus - occurs when the
Ilow oI CSF is blocked along one or more oI the narrow passages connecting the ventricles. One
oI the most common causes oI hydrocephalus is "aqueductal stenosis." In this case,
hydrocephalus results Irom a narrowing oI the aqueduct oI Sylvius, a small passage between the
third and Iourth ventricles in the middle oI the brain.
There are two other Iorms oI hydrocephalus which do not Iit exactly into the categories
mentioned above and primarily aIIect adults: hydrocephalus ex-vacuo and normal pressure
hydrocephalus.
Hydrocephalus ex-vacuo occurs when stroke or traumatic injury cause damage to the brain. In
these cases, brain tissue may actually shrink. Normal pressure hydrocephalus can happen to
people at any age, but it is most common among the elderly. It may result Irom a subarachnoid
hemorrhage, head trauma, inIection, tumor, or complications oI surgery. However, many people
develop normal pressure hydrocephalus even when none oI these Iactors are present Ior reasons
that are unknown.
Who gets this hydrocephalus?
The number oI people who develop hydrocephalus or who are currently living with it is diIIicult
to establish since there is no national registry or database oI people with the condition. However,
experts estimate that hydrocephalus aIIects approximately 1 in every 500 children.
What causes hydrocephalus?
The causes oI hydrocephalus are still not well understood. Hydrocephalus may result Irom
inherited genetic abnormalities (such as the genetic deIect that causes aqueductal stenosis) or
developmental disorders (such as those associated with neural tube deIects including spina biIida
and encephalocele). Other possible causes include complications oI premature birth such as
intraventricular hemorrhage, diseases such as meningitis, tumors, traumatic head injury, or
subarachnoid hemorrhage, which block the exit oI CSF Irom the ventricles to the cisterns or
eliminate the passageway Ior CSF into the cisterns.
Wbat is Hydrocepbalus?
ydrocephalus and congenital hydrocephalus facts
Hydrocephalus is the buildup oI too much cerebrospinal Iluid in the brain. Normally, this Iluid
cushions your brain. When you have too much, though, it puts harmIul pressure on your brain.
There are two kinds oI hydrocephalus. Congenital hydrocephalus is present at birth. Causes
include genetic problems and problems with how the Ietus develops. An unusually large head is
the main sign oI congenital hydrocephalus. Acquired hydrocephalus can occur at any age.
Causes can include head injuries, strokes, inIections, tumors and bleeding in the brain.
Symptoms oI acquired hydrocephalus can include:
O Peadache
O vomlLlng and nausea
O urry vlslon
O aance probems
O adder conLro probems
O @hlnklng and memory probems
Hydrocephalus can permanently damage the brain, causing problems with physical and mental
development. II untreated, it is usually Iatal. With treatment, many people lead normal lives with
Iew limitations. Treatment usually involves surgery to insert a shunt. Medicine and rehabilitation
therapy can also help
What are the symptoms of hydrocephalus?
Symptoms oI hydrocephalus vary with age, disease progression, and individual diIIerences in
tolerance to the condition. For example, an inIant's ability to compensate Ior increased CSF
pressure and enlargement oI the ventricles diIIers Irom an adult's. The inIant skull can expand to
accommodate the buildup oI CSF because the sutures (the Iibrous joints that connect the bones
oI the skull) have not yet closed.
In inIancy, the most obvious indication oI hydrocephalus is oIten a rapid increase in head
circumIerence or an unusually large head size. Other symptoms may include vomiting,
sleepiness, irritability, downward deviation oI the eyes (also called "sunsetting"), and seizures.
Older children and adults may experience diIIerent symptoms because their skulls cannot expand
to accommodate the buildup oI CSF. Symptoms may include headache Iollowed by vomiting,
nausea, papilledema (swelling oI the optic disk which is part oI the optic nerve), blurred or
double vision, sunsetting oI the eyes, problems with balance, poor coordination, gait disturbance,
urinary incontinence, slowing or loss oI developmental progress, lethargy, drowsiness,
irritability, or other changes in personality or cognition including memory loss.
Symptoms oI normal pressure hydrocephalus include, problems with walking, impaired bladder
control leading to urinary Irequency and/or incontinence, and progressive mental impairment and
dementia. An individual with this type oI hydrocephalus may have a general slowing oI
movements or may complain that his or her Ieet Ieel "stuck." Because some oI these symptoms
may also be experienced in other disorders such as Alzheimer's disease, Parkinson's disease, and
CreutzIeldt-Jakob disease, normal pressure hydrocephalus is oIten incorrectly diagnosed and
never properly treated. Doctors may use a variety oI tests, including brain scans (CT and/or
MRI), a spinal tap or lumbar catheter, intracranial pressure monitoring, and neuropsychological
tests, to help them accurately diagnose normal pressure hydrocephalus and rule out any other
conditions.
The symptoms described in this section account Ior the most typical ways in which progressive
hydrocephalus maniIests itselI, but it is important to remember that symptoms vary signiIicantly
Irom one person to the next.
ow is hydrocephalus diagnosed?
Hydrocephalus is diagnosed through clinical neurological evaluation and by using cranial
imaging techniques such as ultrasonography, computed tomography (CT), magnetic resonance
imaging (MRI), or pressure-monitoring techniques. A physician selects the appropriate
diagnostic tool based on an individual's age, clinical presentation, and the presence oI known or
suspected abnormalities oI the brain or spinal cord.
What is the current treatment for hydrocephalus?
Hydrocephalus is most oIten treated by surgically inserting a shunt system. This system diverts
the Ilow oI CSF Irom the CNS to another area oI the body where it can be absorbed as part oI the
normal circulatory process.
A shunt is a Ilexible but sturdy plastic tube. A shunt system consists oI the shunt, a catheter, and
a valve. One end oI the catheter is placed within a ventricle inside the brain or in the CSF outside
the spinal cord. The other end oI the catheter is commonly placed within the abdominal cavity,
but may also be placed at other sites in the body such as a chamber oI the heart or areas around
the lung where the CSF can drain and be absorbed. A valve located along the catheter maintains
one-way Ilow and regulates the rate oI CSF Ilow.
A limited number oI individuals can be treated with an alternative procedure called third
ventriculostomy. In this procedure, a neuroendoscope a small camera that uses Iiber optic
technology to visualize small and diIIicult to reach surgical areas allows a doctor to view the
ventricular surIace. Once the scope is guided into position, a small tool makes a tiny hole in the
Iloor oI the third ventricle, which allows the CSF to bypass the obstruction and Ilow toward the
site oI resorption around the surIace oI the brain.
What are the possible complications of a shunt system?
Shunt systems are not perIect devices. Complications may include mechanical Iailure, inIections,
obstructions, and the need to lengthen or replace the catheter. Generally, shunt systems require
monitoring and regular medical Iollow up. When complications occur, the shunt system usually
requires some type oI revision.
Some complications can lead to other problems such as overdraining or underdraining.
Overdraining occurs when the shunt allows CSF to drain Irom the ventricles more quickly than it
is produced. Overdraining can cause the ventricles to collapse, tearing blood vessels and causing
headache, hemorrhage (subdural hematoma), or slit-like ventricles (slit ventricle syndrome).
Underdraining occurs when CSF is not removed quickly enough and the symptoms oI
hydrocephalus recur. In addition to the common symptoms oI hydrocephalus, inIections Irom a
shunt may also produce symptoms such as a low-grade Iever, soreness oI the neck or shoulder
muscles, and redness or tenderness along the shunt tract. When there is reason to suspect that a
shunt system is not Iunctioning properly (Ior example, iI the symptoms oI hydrocephalus return),
medical attention should be sought immediately.
What is the prognosis for hydrocephalus?
The prognosis Ior individuals diagnosed with hydrocephalus is diIIicult to predict, although there
is some correlation between the speciIic cause oI the hydrocephalus and the outcome. Prognosis
is Iurther complicated by the presence oI associated disorders, the timeliness oI diagnosis, and
the success oI treatment. The degree to which relieI oI CSF pressure Iollowing shunt surgery can
minimize or reverse damage to the brain is not well understood.
AIIected individuals and their Iamilies should be aware that hydrocephalus poses risks to both
cognitive and physical development. However, many children diagnosed with the disorder
beneIit Irom rehabilitation therapies and educational interventions and go on to lead normal lives
with Iew limitations. Treatment by an interdisciplinary team oI medical proIessionals,
rehabilitation specialists, and educational experts is critical to a positive outcome. LeIt untreated,
progressive hydrocephalus may be Iatal.
The symptoms oI normal pressure hydrocephalus usually get worse over time iI the condition is
not treated, although some people may experience temporary improvements. While the success
oI treatment with shunts varies Irom person to person, some people recover almost completely
aIter treatment and have a good quality oI liIe. Early diagnosis and treatment improves the
chance oI a good recovery.
What is carpal tunnel syndrome?
Carpus is a word derived Irom the Greek word karpos, which means "wrist." The wrist is
surrounded by a band oI Iibrous tissue that normally Iunctions as a support Ior the joint. The
tight space between this Iibrous band and the wrist bone is called the carpal tunnel. The median
nerve passes through the carpal tunnel to receive sensations Irom the thumb, index, and middle
Iingers oI the hand. Any condition that causes swelling or a change in position oI the tissue
within the carpal tunnel can squeeze and irritate the median nerve. Irritation oI the median nerve
in this manner causes tingling and numbness oI the thumb, index, and the middle Iingers -- a
condition known as "carpal tunnel syndrome."
What is tarsal tunnel syndrome?
Anatomy similar to that oI the wrist and hand exists in the ankle and Ioot. %arsal is a word
derived Irom the Latin word Ior "ankle." When the sensory nerve that passes through the tarsal
tunnel is irritated by pressure in the tunnel, numbness and tingling oI the Ioot and toes can be
Ielt. This condition is reIerred to as "tarsal tunnel syndrome." Tarsal tunnel syndrome is
analogous to, but Iar less common, than carpal tunnel syndrome. It is treated similarly.
What conditions and diseases cause carpal tunnel syndrome?
For most patients, the cause oI their carpal tunnel syndrome is unknown. Any condition that
exerts pressure on the median nerve at the wrist can cause carpal tunnel syndrome. Common
conditions that can lead to carpal tunnel syndrome include obesity, pregnancy, hypothyroidism,
arthritis, diabetes, and trauma. Tendon inIlammation resulting Irom repetitive work, such as
uninterrupted typing, can also cause carpal tunnel symptoms. Carpal tunnel syndrome Irom
repetitive maneuvers has been reIerred to as one oI the repetitive stress injuries. Some rare
diseases can cause deposition oI abnormal substances in and around the carpal tunnel, leading to
nerve irritation. These diseases include amyloidosis, sarcoidosis, multiple myeloma, and
leukemia.
What are carpal tunnel syndrome symptoms?
People with carpal tunnel syndrome initially Ieel numbness and tingling oI the hand in the
distribution oI the median nerve (the thumb, index, middle, and part oI the Iourth Iingers). These
sensations are oIten more pronounced at night and can awaken people Irom sleep. The reason
symptoms are worse at night may be related to the Ilexed-wrist sleeping position and/or Iluid
accumulating around the wrist and hand while lying Ilat. Carpal tunnel syndrome may be a
temporary condition that completely resolves or it can persist and progress
s Lhe dlsease progresses paLlenLs can deveop a burnlng sensaLlon and/or cramplng and weakness of
Lhe hand uecreased grlp sLrengLh can ead Lo frequenL dropplng of ob[ecLs from Lhe hand Cccaslonay
sharp shooLlng palns can be feL ln Lhe forearm Chronlc carpa Lunne syndrome can aso ead Lo wasLlng
(aLrophy) of Lhe hand musces parLlcuary Lhose near Lhe base of Lhe Lhumb ln Lhe pam of Lhe hand
ow is carpal tunnel syndrome diagnosed?
The diagnosis oI carpal tunnel syndrome is suspected based on the symptoms and the distribution
oI the hand numbness. Examination oI the neck, shoulder, elbow, pulses, and reIlexes can be
perIormed to exclude other conditions that can mimic carpal tunnel syndrome. The wrist can be
examined Ior swelling, warmth, tenderness, deIormity, and discoloration. Sometimes tapping the
Iront oI the wrist can reproduce tingling oI the hand, and is reIerred to as Tinel's sign oI carpal
tunnel syndrome. Symptoms can also at times be reproduced by the examiner by bending the
wrist Iorward (reIerred to as Phalen's maneuver).
The diagnosis is strongly suggested when a nerve conduction velocity test is abnormal. This test
involves measuring the rate oI speed oI electrical impulses as they travel down a nerve. In carpal
tunnel syndrome, the impulse slows as it crosses through the carpal tunnel. A test oI muscles oI
the extremity, electromyogram (EMG), is sometimes perIormed to exclude or detect other
conditions that might mimic carpal tunnel syndrome.
Blood tests may be perIormed to identiIy medical conditions associated with carpal tunnel
syndrome. These tests include thyroid hormone levels, complete blood counts, and blood sugar
and protein analysis. X-ray tests oI the wrist and hand might also be helpIul to identiIy
abnormalities oI the bones and joints oI the wrist.
What is the treatment for carpal tunnel syndrome? Can carpal tunnel syndrome
be prevented?
The choice oI treatment Ior carpal tunnel syndrome depends on the severity oI the symptoms and
any underlying disease that might be causing the symptoms.
Initial treatment usually includes rest, immobilization oI the wrist in a splint, and occasionally
ice application. Those whose occupations are aggravating the symptoms should modiIy their
activities. For example, computer keyboards and chair height may need to be adjusted to
optimize comIort. These measures, as well as periodic resting and range oI motion stretching
exercise oI the wrists can actually prevent the symptoms oI carpal tunnel syndrome that are
caused by repetitive overuse. Underlying conditions or diseases are treated individually.
Fractures can require orthopedic management. Obese individuals will be advised regarding
weight reduction. Rheumatoid disease is treated with measures directed against the underlying
arthritis. Wrist swelling that can be associated with pregnancy resolves in time aIter delivery oI
the baby.
Several types oI medications have been used in the treatment oI carpal tunnel syndrome. Vitamin
B6 (pyridoxine) has been reported to relieve some symptoms oI carpal tunnel syndrome,
although it is not known how this medication works. Nonsteroidal anti-inIlammatory drugs can
also be helpIul in decreasing inIlammation and reducing pain. Side eIIects include
gastrointestinal upset and even ulceration oI the stomach. These medications should be taken
with Iood, and abdominal symptoms should be reported to the doctor. Corticosteroids can be
given by mouth or injected directly into the involved wrist joint. They can bring rapid relieI oI
the persistent symptoms oI carpal tunnel syndrome. Side eIIects oI these medications, when
given in short courses, Ior carpal tunnel syndrome are minimal. However, corticosteroids can
aggravate diabetes and should be avoided in the presence oI inIections.
Most patients with carpal tunnel syndrome improve with conservative measures and medications.
Occasionally, chronic pressure on the median nerve can result in persistent numbness and
weakness. In order to avoid serious and permanent nerve and muscle consequences oI carpal
tunnel syndrome, surgical treatment is considered. Surgery involves severing the band oI tissue
around the wrist to reduce pressure on the median nerve. This surgical procedure is called
"carpal tunnel release." It can now be perIormed with a small diameter viewing tube, called an
arthroscope, or by open wrist procedure. AIter carpal tunnel release, patients oIten undergo
exercise rehabilitation. Though it is uncommon, symptoms can recur.
Caipal Tunnel Synuiome anu Taisal Tunnel Synuiome At A ulance
O Carpa Lunne syndrome ls caused by lrrlLaLlon of Lhe medlan nerve aL Lhe wrlsL
O ny condlLlon LhaL exerLs pressure on Lhe medlan nerve can cause carpa Lunne syndrome
O ympLoms of carpa Lunne syndrome lncude numbness and Llnglng of Lhe hand
O ulagnosls of carpa Lunne syndrome ls suspecLed based on sympLoms supporLed by physlca
examlnaLlon slgns and conflrmed by nerve conducLlon LesLlng
O @reaLmenL of carpa Lunne syndrome depends on Lhe severlLy of sympLoms and Lhe underylng
cause
O Is It Viral or Bacterial?
Meningitis is diIIicult to recognize, understand and diagnose.
Essentially, there are two major divisions oI meningitis -- viral (caused by a virus) and bacterial
(caused by one oI several types and strains oI bacteria residing in the throat or nasal passages).
The bacterial Iorm oI meningitis is extremely dangerous, Iast-moving and has the most potential
Ior being Iatal. For many survivors, the long-term eIIects can be debilitating, possibly including
multiple amputations, hearing loss and kidney damage. Many (but not all) Iorms oI bacterial
meningitis can be prevented by vaccination. Viral meningitis has similar symptoms to bacterial
meningitis, but is neither as deadly nor as debilitating Ior the most part. According to the CDC,
there is no speciIic treatment available Ior viral meningitis at this time. Most patients recover on
their own.
Meningitis is an inIlammation oI the meninges, the membranes that cover the brain and spinal
cord. Most cases are caused by bacteria or viruses, but some can be due to certain medications or
illnesses.
acterial meningitis is rare, but is usually serious and can be liIe-threatening iI not treated right
away. Viral meningitis (also called aseptic meningitis) is relatively common and Iar less
serious. It oIten remains undiagnosed because its symptoms can be similar to those oI the
common Ilu.
Kids oI any age can get meningitis, but because it can be easily spread among people living in
close quarters, teens, college students, and boarding-school students are at higher risk Ior
inIection.
II dealt with promptly, meningitis can be treated successIully. So it's important to get routine
vaccinations, know the signs oI meningitis, and iI you suspect that your child has the illness,
seek medical care right away.
Causes of Meningitis
Many oI the bacteria and viruses that cause meningitis are Iairly common and associated with
other routine illnesses. Bacteria and viruses that inIect the skin, urinary system, gastrointestinal
or respiratory tract can spread by the bloodstream to the meninges through cerebrospinal Iluid,
the Iluid that circulates in and around the spinal cord.
In some cases oI bacterial meningitis, the bacteria spread to the meninges Irom a severe head
trauma or a severe local inIection, such as a serious ear inIection (otitis media) or nasal sinus
inIection (sinusitis).
acterial and Viral Types
Many diIIerent types oI bacteria can cause bacterial meningitis. In newborns, the most common
causes are roup B streptococcus, Escherichia coli, and less commonly, Listeria monocytogenes.
In older kids, Streptococcus pneumoniae (pneumococcus) and Neisseria meningitidis
(meningococcus) are more oIten the causes.
Another bacteria, Haemophilus influen:a type b (Hib), can also cause the illness but because oI
widespread childhood immunization, these cases are now rarer.
Similarly, many diIIerent viruses can lead to viral meningitis, including enteroviruses (such as
coxsackievirus and poliovirus) and the herpesvirus.
$ymptoms of Meningitis
Meningitis symptoms vary, depending both on the age oI the patient and the cause oI the
inIection. Because the Ilu-like symptoms can be similar in both types oI meningitis, particularly
in the early stages, and bacterial meningitis can be very serious, it's important to quickly
diagnose an inIection.
The Iirst symptoms oI bacterial or viral meningitis can come on quickly or surIace several days
aIter a child has had a cold and runny nose, diarrhea and vomiting, or other signs oI an inIection.
Common symptoms include:
O Iever
O lethargy (decreased consciousness)
O irritability
O headache
O photophobia (eye sensitivity to light)
O stiII neck
O skin rashes
O seizures
Meningitis in Infants
InIants with meningitis may not have those symptoms, and might simply be extremely irritable,
lethargic, or have a Iever. They may be diIIicult to comIort, even when they are picked up and
rocked.
Other symptoms oI meningitis in inIants can include:
O jaundice (a yellowish tint to the skin)
O stiIIness oI the body and neck (neck rigidity)
O Iever or lower-than-normal temperature
O poor Ieeding
O a weak suck
O a high-pitched cry
O bulging Iontanelles (the soIt spot at the top/Iront oI the baby's skull)
Viral meningitis tends to cause Ilu-like symptoms, such as Iever and runny nose, and may be so
mild that the illness goes undiagnosed. Most cases oI viral meningitis resolve completely within
7 to 10 days, without any complications or need Ior treatment.
Treatment
Because bacterial meningitis can be so serious, iI you suspect that your child has any Iorm oI
meningitis, it's important to see the doctor right away.
II meningitis is suspected, the doctor will order laboratory tests to help make the diagnosis,
probably including a lumbar puncture (spinal tap) to collect a sample oI spinal Iluid. This test
will show any signs oI inIlammation and whether a virus or bacteria is causing the inIection.
A child who has viral meningitis may be hospitalized, although some kids are allowed to recover
at home iI they are not too ill. Treatment, including rest, Iluids, and over-the-counter pain
medication, is given to relieve symptoms.
II bacterial meningitis is diagnosed or even suspected doctors will start intravenous (IV)
antibiotics as soon as possible. Fluids may be given to replace those lost to Iever, sweating,
vomiting, and poor appetite, and corticosteroids may help reduce inIlammation oI the meninges,
depending on the cause oI the disease.
Possible Complications
Complications oI bacterial meningitis can require additional treatment. For example,
anticonvulsants might be given Ior seizures. II a child develops shock or low blood pressure,
additional IV Iluids and certain medications may be given to increase blood pressure. Some kids
may need supplemental oxygen or mechanical ventilation iI they have diIIiculty breathing.
Some patients who have had meningitis might require longer Iollow-up. One oI the most
common problems resulting Irom bacterial meningitis is impaired hearing, and kids who've had
bacterial meningitis should have a hearing test Iollowing their recovery.
The complications oI bacterial meningitis can be severe and include neurological problems such
as hearing loss, visual impairment, seizures, and learning disabilities. The heart, kidneys, and
adrenal glands also might be aIIected, depending on the cause oI the inIection. Although some
kids develop long-lasting neurological problems, most who receive prompt diagnosis and
treatment recover Iully.
ow Does Meningitis $pread?
Most cases oI meningitis both viral and bacterial result Irom inIections that are contagious,
spread via tiny drops oI Iluid Irom the throat and nose oI someone who is inIected. The drops
may become airborne when the person coughs, laughs, talks, or sneezes. They then can inIect
others when people breathe them in or touch the drops and then touch their own noses or mouths.
Sharing Iood, drinking glasses, eating utensils, tissues, or towels all can transmit inIection as
well. Some inIectious organisms can spread through a person's stool, and someone who comes in
contact with the stool such as kids in daycare may contract the inIection.
InIections most oIten spread between people who are in close contact, such as those who live
together or people who are exposed by kissing or sharing eating utensils. Casual contact at
school or work with someone who has one oI these inIections usually will not transmit the
inIectious agent.
Prevention
Routine immunization can go a long way toward preventing meningitis. The vaccines against
Hib, measles, mumps, polio, meningococcus, and pneumococcus can protect against meningitis
caused by these microorganisms.
Doctors now recommend that kids who are 11 years old get vaccinated Ior meningococcal
disease, a serious bacterial inIection that can lead to meningitis. The vaccine is called
quadrivalent meningococcal vaccine, or MCV4. Kids who have not had the vaccine and are over
11 years old should also be immunized, particularly iI they're going to college, boarding school,
camp, or other settings where they are going to be living in close quarters with others. The
vaccine also may be recommended Ior kids between 2 and 10 years old who have certain high-
risk medical problems, and Ior people traveling to countries where meningitis is more common.
Many oI the bacteria and viruses responsible Ior meningitis are Iairly common, so good hygiene
is an important way to prevent inIection. Encourage kids to wash their hands thoroughly and
oIten, particularly beIore eating and aIter using the bathroom. Avoiding close contact with
someone who is obviously ill and not sharing Iood, drinks, or eating utensils can help halt the
spread oI germs as well.
In certain cases, doctors may give antibiotics to anyone who has been in close contact with the
person who is ill to help prevent additional inIections.
When to Call the Doctor
Seek medical attention immediately iI you suspect your child has meningitis or has symptoms
such as vomiting, headache, lethargy or conIusion, neck stiIIness, rash, and Iever. InIants who
have Iever, irritability, poor Ieeding, and lethargy should also be assessed by a doctor right away.
II your child has had contact with someone who has meningitis (Ior example, in a childcare
center or a college dorm), call your doctor to ask whether preventive medication is
recommended.
Encephalitis Overview
Encephalitis is an acute inIection and inIlammation oI the brain itselI. This is in contrast to
meningitis, which is an inIlammation oI the layers covering the brain.
Encephalitis is generally a viral illness. Viruses such as those responsible Ior causing cold sores,
mumps, measles, and chickenpox can also cause encephalitis. A certain Iamily oI viruses, the
Arboviruses are spread by insects such as mosquitoes and ticks. The equine (meaning horse),
West Nile, Japanese, La Crosse, and St. Louis encephalitis viruses are all mosquito-borne.
Although viruses are the most common source oI inIection, bacteria, Iungi, and parasites can also
be responsible.
The illness resembles the Ilu and usually lasts Ior 2-3 weeks. It can vary Irom mild to liIe-
threatening, and even cause death. Most people with a mild case can recover Iully. Those with a
more severe case can recover although they may have damage to their nervous system. This
damage can be permanent.
O Age, season, geographic location, regional climate conditions, and strength oI the
person's immune system play a role in development oI the disease and severity oI the
illness.
O Herpes simplex (the virus causing cold sores) remains the most common virus involved
in encephalitis in the United States and throughout the world.
O In the United States, there are 5 main viruses spread by mosquitoes: West Nile, Eastern
equine encephalitis (EEE), Western equine encephalitis (WEE), La Crosse, and St. Louis
encephalitis.
O The 1999 New York City outbreak oI West Nile virus, spread by the Culex mosquitoes,
has caused great concern as the virus continues to spread across the US.
O Venezuelan equine encephalitis is Iound in South America. It can be a rare cause oI
encephalitis in Southwestern United States, particularly Texas. The inIection is very mild,
and nervous system damage is rare.
O Japanese encephalitis virus is the most common arbovirus in the world (virus transmitted
by blood-sucking mosquitoes or ticks) and is responsible Ior 50,000 cases and 15,000
deaths per year. Most oI China, Southeast Asia, and the Indian subcontinent are aIIected.
Encephalitis Causes
O erpes simplex: This virus causes cold sores and lesions oI the genitals. It is transmitted
directly through human contact. Newborns can also get the virus by passing through an
inIected birth canal. Once inside the body, the virus travels through nerve Iibers and can
cause an inIection oI the brain. The virus may also undergo a period oI latency in which it
is inactive. At a later time, emotional or physical stress can reactivate the virus to cause
an inIection oI the brain.
O rbovirus: Hosts are animals such as birds, pigs, chipmunks, and squirrels that carry the
virus. Mosquitoes (known as vectors or ways oI transmitting the virus) Ieed on these
animals and become inIected. The virus grows and cycles between the hosts and the
vectors. Humans become inIected through mosquito bites. Once inside the body, the virus
replicates and travels in the bloodstream. II there is a large enough amount oI the virus,
the brain can become inIected. The majority oI cases occur between June and September
when the mosquitoes are most active. In warmer climates, the disease can occur year-
round.
4 West Nile virus (WNV): This virus was Iirst isolated Irom an adult woman with a
Iever in the West Nile District oI Uganda in 1937. The nature oI the virus was
studied in Egypt in the 1950s. In 1957, as a result oI an outbreak in Israel in the
elderly, the WNV became recognized as a cause Ior severe inIlammation oI the
spinal cord and brain in humans. In the early 1960s, it was Iirst noted that horses
were becoming ill in Egypt and France. This virus then emerged in North
America in 1999, with encephalitis reported in humans and horses.
In 1999, 62 cases oI severe disease, including 7 deaths, occurred in the
New York area. In 2001, 21 cases were reported, including 2 deaths in the
New York area. In 2002, 24 deaths have been reported (as oI August 28,
2002).
The virus cycles between the Culex mosquito and hosts such as birds,
horses, cats, bats, chipmunks, skunks, squirrels, and domestic rabbits. The
mosquito Ieeds on the inIected hosts, carries the virus in its salivary
glands, and then passes it on to humans or other animals during a blood
meal. It usually takes 3-15 days Irom the time oI inIection to the onset oI
disease symptoms.
West Nile encephalitis is NOT transmitted Irom person to person (such as
through touching or kissing or Irom a health care worker caring Ior a sick
person) nor can it be passed Irom animal to human.
The chance that you will become severely ill Irom a mosquito bite is
extremely small. According to the Centers Ior Disease Control and
Prevention (CDC), even in areas where mosquitoes are reported to carry
the virus, much less than 1 are inIected. Furthermore, less than 1 oI
the people who get bitten and become inIected will become severely ill.
ThereIore, the majority oI cases are mild, and people can Iully recover.
Prognosis is usually guarded in the extremes oI age (inIants and elderly).
Death as a result oI West Nile encephalitis ranges Irom 3-15 and are
highest among the elderly. At the present time, there is no documented
evidence to suggest that a pregnancy is at risk due to WNV inIection. It is
assumed that iI a person contracts WNV, he or she will develop a natural
immunity that is liIelong. However, it may wane in later years.
Since the virus Iirst appeared in New York, researchers began looking Ior
a vaccine. According to the Proceedings oI the National Academy oI
Sciences, US government scientists have now developed a vaccine that
protects mice Irom the West Nile Virus inIection. Tests showed that mice
injected with this vaccine were protected Irom subsequent exposures to the
New York strain oI West Nile virus. Researchers were expected to begin
testing the vaccine in monkeys in March 2002, with testing in humans
likely to take place in late 2002.
O La Crosse encephalitis: The Iirst case occurred in La Crosse, Wisconsin, in 1963. Since
then, the largest number oI cases has been identiIied in woodland areas oI the
Midwestern and Mid-Atlantic United States. This virus is the most common cause oI
mosquito-borne encephalitis in children younger than 16 years. Each year, about 75 cases
are reported to the Centers Ior Disease Control and Prevention (CDC). The virus cycles
between the daytime-biting treehole mosquito (edes triseriatus) and hosts such as
chipmunks and squirrels. The La Crosse encephalitis virus can cause adverse eIIects on
IQ and school perIormance. About 1 oI people with this inIection die.
O St. Louis encephalitis: Since 1964, an average oI 128 cases are reported per year.
Outbreaks can occur throughout most oI the United States, although large urban
epidemics occurred in the Midwestern and Southeastern regions. The last major epidemic
oI St. Louis encephalitis occurred in the Midwest Irom 1974-1977. There were 2,500
cases in 35 states reported to the CDC. Most recently, there were 20 reported cases in
New Orleans in 1999. The virus cycles between birds and the Culex mosquitoes breeding
in stagnant water. It grows in both the mosquito and the bird but does not make either one
sick. Only the inIected mosquito can transmit the disease to humans during the blood
meal. The virus cannot be transmitted Irom person-to-person through kissing or touching
nor can it be transmitted Irom the inIected bird. The disease tends to aIIect mostly adults
and is generally milder in children.
O Eastern equine encephalitis (EEE): According to the CDC, there have been 153
conIirmed cases in the United States since 1964. This virus is Iound along the East and
GulI coasts. The virus causes severe disease in horses, puppies, and birds such as
pheasants, quails, and ostriches. In humans, Ilulike symptoms develop 4-10 days aIter the
bite oI an inIected mosquito. Usually, human illnesses are preceded by those in horses.
EEE can cause death in 50-75 oI all cases. Those who recover may suIIer severe
permanent brain damage such as mental retardation, seizures, paralysis, and behavior
abnormalities.
O Western equine encephalitis (WEE): This virus was isolated Irom the brain oI a horse
with encephalitis in CaliIornia in 1930. Since 1964, there have been 639 conIirmed cases.
Today, it remains an important cause oI encephalitis in the western part oI the United
States and Canada. In 1994, there were 2 conIirmed and several suspected cases oI WEE
reported in Wyoming. In 1997, 35 strains oI WEE virus were isolated Irom mosquitoes
collected in Scotts BluII County, Nebraska. The WEE virus cycles between certain types
oI birds (small, mostly songbirds) and the Culex tarsalis mosquitoes, a species associated
with irrigated agriculture and stream drainage. The virus has also been Iound in several
other mammals. Horses and humans become sick through mosquito bites. InIants are
particularly aIIected and can have permanent problems such as seizure disorders and
developmental delay.
O Venezuelan equine encephalitis (VEE): This virus is Iound in Central and South America
and is a rare cause oI encephalitis in the Southwestern part oI the United States. It is an
important cause oI encephalitis in horses and humans. From 1969-1971 an outbreak Irom
South America to Texas killed over 200,000 horses. In 1995, there were an estimated
90,000 human inIections with VEE in Columbia and Venezuela. The virus cycles
between Iorest-dwelling rodents and mosquito vectors, especially the species Culex. VEE
inIection in humans is much less severe than that oI WEE and EEE. While adults tend to
develop a Ilulike illness, children tend to develop overt encephalitis. Deaths are rare in
humans but are common in horses. There is an eIIective vaccine Ior horses.
O Japanese encephalitis: This virus is responsible Ior 50,000 cases and 15,000 deaths per
year. Most oI China, Southeast Asia, and the Indian subcontinent are aIIected. The
geographic distribution is expanding. Rarely, cases may appear in United States civilians
and military personnel traveling to and living in Asia. Children and young adults are
mostly aIIected. Older adults are aIIected when there are epidemics in new locations. The
virus cycles between domestic pigs, wild birds, and the Culex tritaeniorhynchus
mosquitoes, which breed in rice Iields. The disease is not transmitted through human
contact, pigs, or birds. Only the mosquitoes can transmit the disease during Ieedings.
Disease
Geographic
Location
Vector/ osts Comment
Herpes
encephalitis
United States/The
world
Human-to-human
contact
Prompt treatment with acyclovir
increases survival to 90
West Nile
encephalitis
AIrica, West Asia,
Middle East, United
States
Mosquito/mostly
birds
Majority are mild cases. Less than 1 oI
those inIected will become severely ill.
Full recovery expected. Vaccine Ior
humans tested late 2002.
Eastern
equine
encephalitis
East Coast (Irom
Massachusetts to
Florida),
GulI Coast
Mosquito/ Birds OIten occurs in horses. High
mortality rate (50-75);
Irequent outcomes (seizures, slight
paralysis), especially
in children
Western
equine
encephalitis
Western United
States and
Canada
Mosquito/ Birds OIten occurs in horses.
Particularly aIIects inIants
Venezuelan
equine
encephalitis
Western
Hemisphere
Mosquito/
Rodents
Rare in United States; low
mortality rate, rare aIter-eIIects
La Crosse
encephalitis
Throughout the
United States,
especially in
Midwestern &
Southeastern
regions
Mosquito/
Chipmunks,
Squirrels
Most common cause oI
encephalitis in children younger
than 16 years old
St. Louis
encephalitis
Midwestern & Mid-
Atlantic
United States
Mosquito/ Birds Mostly aIIects adults
Japanese
encephalitis
Temperate Asia,
southern
and southeastern
Asia
Mosquito/ Birds
and pigs
Vaccine available. See
Prevention section.
High morbidity/mortality rates
$ummary of Viral Encephalitis. Sources: Tierney, et al.; CDC: cdc.gov
Encephalitis $ymptoms
The signs and symptoms oI encephalitis are the same Ior adults and children.
O Signs and symptoms may last Ior 2-3 weeks, are Ilu-like, and can include 1 or more oI
the Iollowing:
4 Fever
4 Fatigue
4 Sore throat
4 StiII neck and back
4 Vomiting
4 Headache
4 ConIusion
4 Irritability
4 Unsteady gait
4 Drowsiness
4 Visual sensitivity to light
O More severe cases may involve these signs and symptoms:
4 Seizures
4 Muscle weakness
4 Paralysis
4 Memory loss
4 Sudden impaired judgment
4 Poor responsiveness
When to $eek Medical Care
Call your doctor Ior immediate advice iI you develop signs and symptoms oI encephalitis and
you have any oI these conditions:
O You have sores around the lips or genitals through contact with another person.
O You were in wooded or Iorest areas and suspect mosquito bites.
O You were visiting an area where these diseases are common, especially outside the
United States.
O You were bitten by a tick.
II you develop signs and symptoms oI encephalitis and your doctor is not available, go
immediately to a hospital's Emergency Department Ior Iurther evaluation. Do not hesitate or
decide on your own that you simply have the Ilu. Symptoms indicating severe illness require
emergency treatment.
Exams and Tests
Geographic location and seasonal occurrence can help identiIy the speciIic cause oI encephalitis.
Depending on your unique situation, the doctor may perIorm 1 or more oI the Iollowing tests:
O A picture oI the brain such as a CT scan or magnetic resonance imagining (MRI) is oIten
done. MRI is the procedure oI choice iI herpes encephalitis is suspected.
O A DNA study called polymerase chain reaction (PCR) has greatly improved the diagnosis
oI herpes encephalitis.
O A reading oI the electrical activity oI the brain with an EEG can detect irregularities.
Herpes encephalitis produces a characteristic EEG pattern.
O A lumbar puncture, also known as a spinal tap, may be necessary to isolate the virus.
During this procedure, the doctor applies local numbing medication and then inserts a
needle into your lower back to collect Iluid Irom the space around the spinal column Ior
analysis.
O The virus may also be isolated Irom tissue or blood.
O Brain biopsy is an option although it is rarely done and usually only iI the other tests do
not give an answer.
Encephalitis Treatment
$elf-Care at ome
Because encephalitis can cause death, seek treatment in a hospital's emergency department. Any
home treatment to relieve the Ilulike symptoms should be carried out according to the doctor's
advice and recommendation aIter diagnosis.
Medical Treatment
Encephalitis is usually a viral illness, which means that antibiotics are not used to treat it. The
only available vaccine Ior prevention is Ior Japanese encephalitis.
O With the exception oI herpes encephalitis, the mainstay oI treatment is symptom relieI.
People with encephalitis are kept hydrated with IV Iluids while monitoring Ior brain
swelling. Anticonvulsants can be given Ior seizure control. Steroids have not been
established as being eIIective.
O Herpes encephalitis can cause rapid death iI not diagnosed and treated promptly.
ThereIore, medication is usually started when the doctor suspects herpes to be the
diagnosis without waiting Ior the conIirmatory results. The recommended treatment is
acyclovir (Zovirax) given by IV Ior 2-3 weeks. Acyclovir-resistant herpes encephalitis
can be treated with Ioscarnet (Foscavir). Liver and kidney Iunctions are monitored
through the course oI medication.
O Currently, the use oI ribavirin (Rebetol, Virazole) in the treatment oI a child with La
Crosse encephalitis is being studied.
ollow-up
It is important to Iollow up with your doctor aIter the initial treatment because certain nervous
system problems can develop aIter what appears to be a successIul initial treatment. Relapse can
occur with herpes encephalitis
Prevention
O Seek early treatment Ior any high Iever or inIections.
O Wear long pants and long-sleeved shirts to avoid ticks and mosquitoes when in Iorests or
grassy areas.
O Use insect repellant in exposed areas oI the body.
O Avoid spending a long time outdoors during dusk when insects tend to bite.
O National surveillance and control oI mosquitoes through aerial spraying can keep insect
populations under control.
O A Caesarian section (C-section) can be perIormed iI the mother has active herpes lesions
to protect the newborn.
O Vaccinate children against viruses that can cause encephalitis (measles, mumps).
O Japanese encephalitis can be prevented with 3 doses oI the vaccine. Take precautions
when traveling to areas where this strain is common.
4 According to the Centers Ior Disease Control and Prevention, the vaccine is NOT
recommended Ior all travelers to Asia. It should be oIIered to people spending a
month or longer in areas where the disease-causing mosquitoes are known to be
and during the transmission season. However, travelers spending Iewer than 30
days should receive the vaccine iI the area is experiencing an epidemic outbreak.
4 The beneIit oI the vaccine should be weighed against the side eIIects and the risk
oI developing the disease by getting the shot. The risk oI developing serious
allergic reaction such as hives is low.
4 Special consideration should be given to the elderly and pregnant women. The
elderly have a higher chance oI developing symptoms with inIection. The
Japanese encephalitis virus can inIect the Ietus and cause death. ThereIore, these 2
groups should be cautious when traveling abroad.
Outlook
The outcome oI the disease varies and depends on Iactors such as age, severity oI the case, and
strength oI the immune system. For example, people who are HIV positive, have cancer, or other
illnesses have a weaker immune system and are less able to withstand another disease. In
general, those with mild cases will recover without any problems.
O The death rate Ior viral encephalitis can be high.
O The St. Louis encephalitis virus can cause death in up to 30 oI the cases.
O Japanese encephalitis can cause death in up to 60 oI the cases, usually within the Iirst
week oI illness.
O In untreated cases oI herpes encephalitis, 50-75 oI people die within 18 months.
Acyclovir (Zovirax) can increase survival up to 90.