ISPN 2008: Yesterday was Great

Yesterday was a remarkable day. I presented our work "Endoscopic Management of Hydrocephalus in Nigerian Children" to the over-600 international audience from over 50 countries at the 36th congress of the International Society for Paediatric Neurosurgery. You would agree with me that it is an honour to present alongside the likes of Ben Warf and Michael Fritsch and to an audience that included the great Hal Rekate and Schuzio Oi.

The paper presentations were followed by an evening of wine tasting during which poster presentations were made. I presented a classic poster on "The profile of hydrocephalus in Nigerian Children with Myelomeningocoele" under the guidance of my mentor and trainer, Professor M. T. Shokunbi.

I shall keep you posted on further developments at the congress. The weather here is getting progressively colder. I now use warmer in my room.

Catch u.

Clinical Features of Hydrocephalus

Clinical presentation of hydrocephalus depends on the age of the affected individual and the rate of CSF accumulation. In infants, the most striking feature is the abnormal increase in the size of the head whereas in adults, it commonly presents with features of raised intracranial pressure.

In young children, hydrocephalus could present with any combination of the following symptoms and signs:

• Abnormally large head; usually with the rate of growth of the cranium greater than that of the face (craniofacial disproportion)
• Irritability
• Poor neck/head control
• Poor developmental milestone attainment/loss of previously attained milestones such as social amile, neck control, sitting, walking and talking
• Nausea and vomiting
• Bulging fontanelle(s)
• Widening of the cranial sutures (sutural diastasis)
• Prominent, enlarged and engorged scalp veins
• ‘Setting sun sign’ or sunset appearance of the eye due to paralysis of upward gaze (Parinaud syndrome) from pressure of the accumulated CSf in the suprapineal recess on the tectum of the midbrain
• Sixth nerve (abduscens) palsy (due to its long intracranial course)
• Macewen’s sign: cracked pot sign on percussion of the skull
• Miscellaneous findings
o Hyperactive reflexes
o Irregular respirations with apneic spells

In older children/adults, it presents with features of increased ICP:
• Headache
• Nausea and vomiting
• Gait abnormalities
• Papilloedema
• Upward gaze palsy
• Sixth nerve palsy

If the ventricles enlarge slowly, the condition may initially be asymptomatic.
The classic triad of normal pressure hydrocephalus is:
• Dementia
• Urinary incontinence
• Gait ataxia

Causes of Hydrocephalus

The conditions causing hydrocephalus include the following:

• Excessive CSF production by the choroid plexuses
o Choroid plexus papilloma

• Blockage in the CSF circulation, either within the ventricle, or on the outside of them
o Aqueductal stenosis
o Tumours
o Chiari malformation especially types I and II
o Dandy-Walker malformation
o Intraventricular haemorrhage
o Meningitis
o Spinal tumour
o Myelomeningocoele

• Impairment of CSF absorption by the arachnoid villi.
o Meningitis
o Subarachnoid haemorrhage

The causes enumerated above could also be classified into congenital or acquired.

Hydrocephalus: Introduction

Hydrocephalus is a neurosurgical condition in which there is excessive accumulation of brain water (called cerebrospinal fluid) in the head. Hydro = water; cephalus = head. It is rare but certainly present in our community.

Many of the children, and alas! Adults that you see around with big heads suffer from this condition. Do not stigmatize the sufferer, it is definitely not his/her making.

The causes of the condition are many; some are congenital (occur before birth) while some others are acquired (contracted after birth). To properly understand the causes of hydrocephalus, you need to appreciate the formation and flow of the brain water. A simple overview of this is as follows:

• The brain has large spaces within it called the ventricle (four of them, called right lateral, left lateral, third & fourth)

• The ventricles communicate with a space surrounding the brain, called the subarachnoid space through openings (foramina in the 4th ventricle)

• The subarachnoid space in turn coomunicates with a similar space surrounding the spinal cord

• Cerebrospinal fluid (CSF) is produced by flower like structures in the ventricles called the choroid plexus

• The fuid circulate in the ventricle and into the subarachnoid space (around the brain and the spinal cord)

• The fluid get absorbed into the blood stream via finger-like structures called arachnoid villi located in the coverings of the brain

• CSF production is in dynamic balance with absorption to prevent its accumulation.

From the foregoing, you would probably have deduced that hydrocephalus can result from:
1. Excessive CSF production by the choroid plexuses
2. Blockage in the CSF circulation, either within the ventricle, or on the outside of them
3. Impairment of CSF absorption by the arachnoid villi.

Simple isn’t it? You don’t have to be a genius to understand this. Watchout for my updates on this topic. I will appreciate your feedback on how useful you think this introduction is. I will also make myself available on this site to answer any question that bothers you about this very important condition. In addition, I shall appreciate your comments on the topic.

Join this discussion.

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