Pediatric Hydrocephalus

Hydrocephalus is the accumulation of cerebrospinal fluid in the brain cavities (ventricles) for different reasons. Excessive accumulation of fluid in the fluid-filled cavities in the brain can create various findings by pressing to the brain, in the situation of different diseases. Hydrocephalus may be congenital (primary hydrocephalus) as well as may develop as a result of different brain diseases (secondary hydrocephalus). Examples of these diseases include meningocele, meningomyelocele, encephalocele, malformation of Dandy-Walker, and other rare congenital defects.

Hydrocephalus is the growth and expansion of ventricles filled with cerebrospinal fluid in the brain tissue as a result of the increase of this fluid. In normal healthy individuals, the cerebrospinal fluid is produced by specialized cells in these chambers and is reabsorbed after flow through the chambers and cortex of the brain and around the spinal cord. The reason for this increase in hydrocephalus is either the increase in the production of this fluid or the reduction of its absorption. Sometimes the fluid can accumulate in the ventricles and hydrocephalus may develop as a result of congestion due to congenital adhesion or tumor on the ways while going to the region where it is absorbed.

Symptoms: Symptoms of hydrocephalus may vary by age.

In newborn (0-2 months): Abnormal growth of the head than normal, thinning of the scalp, becoming evident of the veins in the head, vomiting, restlessness, eyes that sliding down, seizures or noncommunicable situation

In children (2 months and up): Abnormal growth of the head, headache, nausea, vomiting, fever, diplopia (double vision), restlessness, deficiency in speech and/or walking, communication disorder, loss of sense and motor functions, seizures, vision disorders may be seen. Older children may have difficulty staying awake or waking up.

Diagnosis:

  1. Magnetic Resonance Imaging (MRI) is the gold standard. With these examinations, the brain’s own tissue can be evaluated in detail. In addition, the movement of cerebrospinal fluid in the brain tissue between cells and the flow of this fluid in and around the brain and the ventricle and channels can also be evaluated. In addition, pathologies such as tumor causing hydrocephalus can also be detected.
  2. Magnetic resonance imaging (MRI) methods that show the cerebrospinal fluid flow. These examinations are especially used in cases that prevent the flow of cerebrospinal fluid. Although large tumors and other large-scale pathologies that inhibit fluid flow can be diagnosed by normal MRI, small sized tumors and sometimes narrownesses and obstructions that are congenital or acquired which are in the way of fluid flow may not be seen in MRI. MRI examinations showing cerebrospinal fluid flow may also be used in these cases.
  3. Diagnosis can be made by ultrasonography in newborns.
  4. Computed tomography (CT) is also frequently used in hydrocephalus, although it is better to detect bone tissue. It also shows bleeding in patients with new bleeding.

Treatment

  1. Placing a shunt: The purpose of shunt insertion is to transfer the accumulated excess fluid in the brain cavities into different spaces of the body. In this process, a catheter is inserted into the ventricles in the head, this catheter is connected with the pump, a second longer catheter is connected to the other end of the pump, this catheter is carried under the skin into the abdominal cavity and its tip is placed inside the abdomen. In this way, the excess fluid in the brain is transferred into the abdomen. Excess fluid is absorbed from the abdomen. Combining the catheters leading to the brain and abdomen just above the skull, the pump allows the cerebrospinal fluid to flow controlledly over a certain pressure. In this way, the fluid accumulated in the brain is discharged to another part of the body. The abdominal cavity is often used to drain this fluid. The other end of the catheter that goes to the abdomen can also be connected to different parts of the body. In some cases, this fluid may be evacuated to the chest cavity or to the heart with the help of a vena which goes from neck to the heart. The shunt pumps that are used can be of constant pressure setting and can be changed from outside after adjustment. The choice is made according to the clinical status of the patients. Patients with a shunt are closely monitored. Failure in shunt or infection may be seen. Infection usually occurs in the first 6 weeks after surgery, but also may be seen later. Shunts with antibiotics may be used in patients with a recurrent shunt infection.
  2. Endoscopic third ventriculostomy: This treatment option can be applied in the time of mechanical obstruction of the ways that provide the fluid transfer. Each patient with hydrocephalus may not be suitable for this treatment. In this treatment option, to ensure fluid flow in the ventricles (fluid-filled spaces of the brain), a new hole is opened by the endoscope by entering to these spaces and the flow of accumulated fluid is ensured.