Hydrocephalus can be split into two root words: “hydro” is water and “cephalus” is head. Hydrocephalus is a condition where there is a build up of cerebrospinal fluid (CSF) in the ventricles of the brain. This condition can increase pressure in the head. The “water” part of hydrocephalus refers to the CSF. The main jobs of CSF:
- Works to absorb shock for the brain and spinal cord
- Deliver nutrients to the brain and removes waste
- Regulated the changing pressures within the brain as it flows in the cranium and spine
A typical adult will make around one pint of CSF every day. If the circulation of CSF is affected from an injury or illness, the ventricles can become swollen or enlarged as CSF builds up. Adults have very rigid skulls that cannot expand and withstand an increase in pressure.
Hydrocephalus is a chronic condition that cannot typically be cured but can be controlled. It is possible to live a normal life when this condition is treated early.
Hydrocephalus can affect people of any age but it is most often seen in infants and adults over the age of 60. Age and race are affected equally. According to research, around 5-6% of dementia is caused by normal-pressure hydrocephalus.
HYDROCEPHALUS EX-VACUO
Hydrocephalus ex-vacuo happens due to brain damage from a stroke or injury that has caused the brain matter to shrink. In older patients with dementia, the brain may shrink and CSF will fill in the new space. When this happens, the ventricles become large but pressure is still normal.
NORMAL PRESSURE HYDROCEPHALUS (NPH)
The slow blockage of CSF drainage pathways in the brain lead to Normal Pressure Hydrocephalus. When the volume of CSF increases, the ventricles become enlarged which compress the brain and over time lead to damaged brain tissue. NPH has enlarged ventricles in the brain even though there is little or no pressure increase. The name can be misleading as the pressure levels of some patients with NPH can change.
A head injury, cranial surgery, hemorrhage, meningitis, or tumor can cause Normal Pressure Hydrocephalus. There are also many unknown reasons for NPH. Some symptoms of NPH are similar to symptoms that develop with age and also are similar to some symptoms of Alzheimer’s or Parkinsons. Most people with NPH are over the age of 60 and most people think that their symptoms are only contributed by aging. This can cause people to go undiagnosed and untreated for Normal Pressure Hydrocephalus.
SYMPTOMS OF ADULT ONSET HYDROCEPHALUS
- Headaches
- Nausea
- Trouble focusing the eyes
- Unsteady walking
- Weakness in legs
- Sudden falls
- Irritability
- Drowsiness
- Personality or behavior change
- Seizures
Primary symptoms of NPH
- Difficulty walking
- Dementia
- Bladder issues
Patients with NPH have a gait disturbance (difficulty walking). This gait is wide-based, slow, short, and shuffles. People may struggle to pick up their feet as they walk and may fall often. This is one of the most clear symptoms related to NPH. The gait disturbance can vary in severity.
If NPH is left undiagnosed or untreated, the symptoms can steadily progress. Patients may have seizures that can also get worse over time, dementia, or bladder problems. Mild dementia typically results in loss of interest in normal activities, being forgetful, trouble with simple tasks, and short term memory loss.
The bladder issues that may arise from NPH include urinary frequency in the more mild cases. A complete loss of bladder control may arise in more severe cases. The urinary urgency is the need to use the bathroom extremely frequently and sometimes uncontrollably.
DIAGNOSING HYDROCEPHALUS
If a patient presents with the main NPH symptoms, a neurosurgeon should immediately be contacted. A patient will need to have his or her medical history reviewed, an examination, neurological testing, and more. The neurological exam is important to determine how severe the condition is. Some tests that may be done are a CT scan, MRI, isotopic cisternography, lumbar puncture, intracranial pressure monitoring.
SURGERY
There are multiple ways to treat hydrocephalus. There is a direct path of treatment by removing the cause of the CSF blockage. There is an indirect path of treatment that diverts the CSF to another body cavity. Indirect treatment is done by placing a device called a shunt in the brain that will divert the extra CSF away from the brain. This is usually diverted into the peritoneal cavity.
Other cases may need two procedures done. This consists of diverting the CSF and removing the obstruction which can include a brain tumor. The shunt typically will stay in the patient for the rest of their life. This shunt will keep the pressure in the brain at normal levels by continually diverting CSF from the brain.
An endoscopic third ventriculostomy is another surgery that could be done. A small burr hole will be made into the skull. A neuroscope will be placed into the skull which is a camera. A small hole will be made in the third ventricle to create a new pathway for the CSF to flow.
RECOVERY
After surgery, the patient will have their neurological function evaluated. Rehab cause possibly be needed. Depending on how much damage has already been done to the brain by hydrocephalus and the brain ability to heal, complete recovery may not happen.
Since hydrocephalus is a chronic condition, follow ups with the doctor will be needed. Tests, suchs as a CT scan, MRI, or an X-ray, are helpful to check how the shunt is working. Check in with the doctor if any of these postoperative symptoms happen:
- redness , pain, swelling of skin along tube or incision
- Drowsiness or irritability
- Nausea, vomiting, headaches, double vision
- Fever
- Abdominal pain
- Preoperative neurological symptoms
PROGNOSIS
Depending on the symptoms, timeline, cause, and severity, the prognosis for hydrocephalus will vary. Some patients have a great recovery while others do not recover. Sometimes dementia can be reversed after the placement of a shunt. Headaches may immediately disappear if caused by elevated pressure levels. Life NPH website claims that if the cause of NPH is known, the success rate is 80% for the shunt procedure. Success is around 25-74% when the cause is unknown.
The earlier hydrocephalus can be diagnosed, there is a greater chance of recovery. There is no way to predict whether or not surgery will work.
Shunt malfunction can also happen. The valve can get jammed or clogged. The pressure in the shunt might not be able to match the patient’s needs. Additional surgery could be possible. There could be infections that need treatment. Pay attention to these symptoms of possible shunt malfunction: irritability, fatigue, change in personality, coordination loss, trouble being awake, walking trouble, dementia. Most complications can be fixed.
