1. WILL WESTON 4 TH Year Medical Student HYDROCEPHALUS IN CHILDHOOD

2. 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) BOBBY: 6 Year ♂

3. PREGNANCY & LABOUR… Normal Pregnancy…up until… 33+4 / 40 …CTG: Fetal Distress (tachycardia)  ARM + Syntocinon  Vaginal Delivery

4. 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)

5. HYDROCEPHALUS- DEF: Disturbance of …FORMATION / FLOW /ABSORPTION … of CSF   Volume occupied in the CNS.

6. HYDROCEPHALUS- DEF: Disturbance of …FORMATION / FLOW /ABSORPTION … of CSF   Volume occupied in the CNS. FORMATION FLOW (indirectly inhibits absorption) ABSORPTION

8. 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:

9. 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

10. SYMPTOMS… in Infants:  Poor feeding & Activity  Irritability & Vomiting  Head enlargement  Dysjunction of sutures & Tense fontanelle  Dilated scalp veins  Setting-sun sign: Characteristic in infants of  ICP.  Increased limb tone SIGNS… in Infants:

11. SYMPTOMS… in Children:  Slowing of mental capacity  Headaches, Vomiting & Drowsiness  Neck pain  Blurred vision  Double vision  Difficulty in walking

12. SIGNS… in Children:  Papilledema

14. SIGNS… in Children:  Papilledema  Failure of upward gaze  Macewen sign: "cracked pot“  Unsteady gait  Large head  Unilateral / bilateral 6 th nerve palsy

15. INVESTIGATIONS:  ULTRASOUND (Evaluates intraventricular haemorrhage)  SKULL X RAY:  CT / MRI

16. INVESTIGATIONS:  ULTRASOUND (Evaluates intraventricular haemorrhage)  SKULL X RAY:  CT / MRI

17. 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)

18. MANAGEMENT- Sx (SHUNT):  Establish communication between CSF and drainage cavity.

19.  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.

20. 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.

21. 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’…

22. ‘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

23. MANAGEMENT PLAN…  School Diary  Video Footage: Parents & Teachers’ Mobile Phones  EEG  Mental retardation, Cerebral palsy and EPILEPSY are known to be related to infantile hydrocephalus 1,2 1.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. 2.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.

24. Any Questions