Pediatric Hydrocephalus
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Pediatric hydrocephalus is a buildup of fluid in the brain at the time of birth or during infancy, childhood, or adolescence. Most often, the primary treatment for this condition is surgery to drain the fluid, and a child’s outcome is often excellent.
Hydrocephalus is one of the problems pediatric neurosurgeons see most frequently. It is also known as “water on the brain,” but that term is actually a misnomer. In reality, most cases of hydrocephalus represent a buildup of cerebrospinal fluid (CSF) inside the brain.
Everyone continuously produces CSF, a fluid very similar to the liquid portion of blood. It contains various salts as well as other products, such as sodium and glucose. Primarily produced in the ventricles, the fluid circulates through the ventricle system and around the brain and spinal cord. Eventually, the CSF is reabsorbed over the surface of the brain into large veins, where CSF mixes with blood and is transported to the heart. This orderly cycle of CSF production, flow, and absorption maintains a protective environment for the central nervous system.
Symptoms
During early infancy, hydrocephalus is usually detected by the family or pediatrician as macrocephaly; macrocephaly rarely occurs later in infancy and childhood.
Additional common symptoms for infants include:
- Vomiting
- Eye gaze pointed downward
- Progressive weakness and spasticity
- Poor feeding
- Failure to thrive
- Delay or loss of developmental milestones
- Unusual sleepiness
- Nystagmus
- Irritability
Diagnosis
A neurological examination is usually performed to identify alterations in brain function and mental status. This exam consists of assessing eye movements, vision, hearing, swallowing, motor function, sensation, balance, and coordination.
Depending on the child’s age at the time of discovery, various imaging techniques are available to confirm the diagnosis.
In the first six to 12 months of life, the diagnosis can often be made with an ultrasonography of the brain because the sutures in an infant’s skull have not yet fused. Plain X-rays of the skull and measurements of the head can also lead to a diagnosis for infants.
Risk Factors
Pediatric hydrocephalus occurs when the orderly balance of cerebrospinal fluid (CSF) in the brain is altered. This disruption can occur when CSF is overproduced, not properly absorbed or obstructed by a blockage.
Possible causes include bleeding, infection, trauma, tumors, vascular problems, and structural problems.
Hydrocephalus can occur during pregnancy, and when it does, it is labeled congenital hydrocephalus; about one to two per 1,000 babies are born with congenital hydrocephalus. Other instances of hydrocephalus arise after birth.
Treatments
At Columbia, our pediatric neurosurgeons treat hundreds of patients each year and use the most sophisticated surgical techniques, resulting in the best possible outcomes.
If the diagnosis of hydrocephalus has been made, there are rarely options other than surgery for treatment. If a definable mass is causing the obstruction of cerebrospinal fluid flow, it may be possible to remove the mass and allow for normal flow and resolution of the hydrocephalus. However, more often than not, the blockage cannot be removed, and surgical intervention to reroute the fluid is needed.
Most surgeons use systems called shunts to channel the fluid from the ventricles to other sites in the body such as the abdominal cavity, chest cavity, or heart. Each of these sites has various advantages and disadvantages, but the most popular choice by far among neurosurgeons performing pediatric surgery is the abdominal cavity. Here, the CSF is absorbed onto the surface of the bowels to be returned to the bloodstream along with the vital salts and other products it contains.
There are many different shunt systems on the market. In its simplest form, a shunt is an inert plastic tube less than an eighth of an inch thick that allows fluid to flow through it in one direction. There is usually a valve system that regulates the volume of flow as well. The shunt is surgically placed in the brain by drilling a small hole in the skull; a reservoir or “bubble” can be felt through the scalp once the procedure is complete. This reservoir allows for sampling of the CSF with a tiny needle, if indicated, to test for function or infection. (Like all implanted devices, shunts can malfunction or become infected and need to be replaced.)