HYDROCEPHALUS

Supervised by:
dr. Lamhot Asnir Lumban Tobing, Sp.BS
Presented by:
Joanna Febrila (2014-061-048)
Aurelia Puspaningrum (2014-061-052)

Definition
Excessive accumulation of cerebrospinal fluid
within the ventricular system of the brain (
production, absorption, obstruction on the
pathways)
Normal condition
Fine balance between CSF production by the
choroid plexus and absorption at the
arachnoid villi along the superior sagittal
sinuses.
CSF production has been found to be 0.33
mL/kg/hr (20 mL/hr).
Almost all the fluid produced is absorbed

Communicating - Obstructive

Obstructi
ve

Obstruction is at or proximal to
the fourth ventricular outlet
foramina (foramen of
Magendie, foramen of
Luschka).
Ex. : aqueductal stenosis,
tumors

Communicati
ng

Beyond the fourth ventricular

outlet foramina (cisterns or
arachnoid granulations)
Ex. : infection, hemorrhage into
the ventricles, trauma

Acute - Chronic

Acute

Hydrocephalus developing within days

or few weeks
Manifests with rapid progression of
symptoms
Ex. : hydrocephalus caused by tumor

Chroni
c

CSF accumulation over months (or even

years)
Presents with subtle signs of memory
impairment, walking difficulty, or urinary
incontinence
Ex. : normal pressure hydrocephalus
(NPH)

At times, chronic hydrocephalus can present acutely because of

changes in the pathophysiology of the CSF absorption/flow

Congenital - Acquired
Congenit
al

Present at birth (a few weeks months after birth, process may

even have started while was in
utero)
Commonly obstructive in nature
It can be communicating
(intrauterine toxoplasmosis /
cytomegalovirus infections)

Acquired

Pathologic process starts after birth

Includes post-traumatic
hydrocephalus, tumors, NPH

Clinical Manifestation
Infants & Children

Adults

Abnormal head
Chronic headache
enlargement
Difficulty walking /
Tense, bulging fontanel
gait disturbances
Prominent scalp veins
Cognitive
Skull bones might felt
complaints
separated
Urinary urgency or
Headache, nausea,
incontinence
vomiting, vision
problem ICP
Downward deviation of
eyes
The following imaging studies may be used to
evaluate patients with suspected hydrocephalus:
CT scan : assess size of ventricles and other
structures
MRI : considerable value in diagnosing the exact

Pathophysiology
Normal route of CSF from production*Normal CSF
production :
0.33 mL/kg/hr (20
mL/hr),
most CSF is produced by
the choroid plexus
*The capacity of the
lateral and third
ventricles in a healthy
person is 20 mL
*ICP rises if production
of CSF exceeds
absorption
(CSF overproduced,
resistance to CSF flow,
venous sinus pressure is
increased)
*CSF production falls as
ICP

clearance :
*Choroid plexus -> lateral ventricle ->
interventricular foramen of Monro ->
third ventricle -> cerebral aqueduct of
Sylvius
-> fourth ventricle -> 2 lateral foramina
of Luschka & 1 medial foramen of
Magendie ->
subarachnoid space -> arachnoid
granulations
-> dural sinus -> into the venous
drainage
Compensation
:
temporal & frontal horns dilate first,
often asymmetrically ->
*elevation of the corpus callosum
*stretching/ perforation septum
pellucidum
*thinning of the cerebral mantle
*enlargement of the third ventricle
downward into the pituitary fossa

Radiologic examination
X-ray
USG
CT scan
MRI

CT Scan

MRI

Treatment
Pharmacotherapy

temporary
Non obstructive hydrocephalus
Surgery

Definitive therapy

Pharmacotherapy
Reduce production of CSF
Asetazolamid
PO / IV : 20-100 mg/kg/day divided into 3
doses,
maximal dose 2 gram / day.
Improve resorption of CSF
Furosemid
IV : 1-2 mg/kg/dose, given 2-4 times / day
PO : 1-6 mg/kg/dose, given 1-2 times / day

Surgery

Gold standard :
Ventriculoperitoneal Shunt

Shunt Complication

Malfunction
Obstruction
Infection
Over-drainage
Brain injury, intracranial bleeding

Daftar Pustaka
Schwartz S, Brunicardi F. Schwartz
Principles of Surgery 10th ed. New
York: McGraw-Hill medical;2011
Townsend C. Sabiston Textbook of
Surgery 19th ed. Elsevier Health
Sciences;2012