Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
MSD MANUAL
Professional Version
The trusted provider of medical information since 1899
Hydrocephalus
By Stephen J. Falchek , MD, Nemours/Alfred I. duPont Hospital for Children
Hydrocephalus is the most common cause of abnormally large heads in neonates. Hydrocephalus that develops only
after the fontanelles have closed does not increase head circumference or cause the fontanelle to bulge but can
markedly and rapidly increase intracranial pressure.
Etiology
Hydrocephalus can result from
Obstruction of CSF flow (obstructive hydrocephalus)
Dandy-Walker malformation
Aqueductal stenosis is narrowing of the outflow pathway for CSF from the 3rd ventricle to the 4th ventricle. It may be
either primary, or secondary to scarring or narrowing of the aqueduct resulting from a tumor, hemorrhage, or
infection. Primary aqueductal stenosis may involve true stenosis (forking of the aqueduct into smaller, poorly
functioning channels) or presence of a septum in the aqueduct. Primary aqueductal stenosis may be inheritable; there
https://www.msdmanuals.com/professional/pediatrics/congenital-neurologic-anomalies/hydrocephalus# 1/4
11/10/2019 Hydrocephalus - Pediatrics - MSD Manual Professional Edition
are many genetic syndromes, some of which are X-linked (thus male infants inherit the condition from otherwise
unaffected mothers).
Dandy-Walker malformation comprises progressive cystic enlargement of the 4th ventricle in fetal life, resulting in
complete or partial agenesis of the cerebellar vermis and hydrocephalus. It is likely related to a failure of formation of
the foramen of Magendie in the fetus. Associated anomalies of the CNS are common, including agenesis of the corpus
callosum and heterotopias. Dandy-Walker malformation accounts for 5 to 10% of cases of congenital hydrocephalus.
In Chiari II (formerly Arnold-Chiari) malformation, hydrocephalus occurs with spina bifida and syringomyelia.
Significant elongation of the cerebellar tonsils in Chiari I type malformation or midline vermis in Chiari II causes them
to protrude through the foramen magnum, with beaking of the colliculi and thickening of the upper cervical spinal
cord.
Impaired resorption in the subarachnoid spaces usually results from meningeal inflammation, secondary either to
infection or to blood in the subarachnoid space, resulting from either subarachnoid hemorrhages or intraventricular
hemorrhages, which are complications of delivery, particularly in premature infants.
Etiology reference
1. Shaheen R, Sebai MA, Patel N, et al: The genetic landscape of familial hydrocephalus. Ann Neurol 81(6):890–897,
2017. doi: 10.1002/ana.24964.
Diagnosis
Prenatal ultrasonography
Treatment
Sometimes observation or serial lumbar punctures
Treatment of hydrocephalus depends on etiology, severity, and whether hydrocephalus is progressive (ie, size of the
ventricles increases over time relative to the size of the brain). Mild, nonprogressive cases may be observed with serial
imaging studies and measurement of head size. To temporarily reduce CSF pressure in infants, ventricular taps or
serial lumbar punctures (if the hydrocephalus is communicating) may be used.
Progressive hydrocephalus usually requires a ventricular shunt. Shunts typically connect the right lateral ventricle to
the peritoneal cavity or, rarely, to the right atrium via a plastic tube with a one-way, pressure-relief valve. When a shunt
is first placed in an infant or older child whose fontanelle is closed, rapid withdrawal of fluid can cause subdural
bleeding as the brain shrinks away from the skull. When the fontanelles are open, the skull can decrease in
https://www.msdmanuals.com/professional/pediatrics/congenital-neurologic-anomalies/hydrocephalus# 2/4
11/10/2019 Hydrocephalus - Pediatrics - MSD Manual Professional Edition
circumference to match the decrease in brain size; thus, some clinicians recommend an early decision regarding shunt
placement so that it can be done before fontanelle closure.
In a third ventriculostomy, an opening is created endoscopically between the 3rd ventricle and the subarachnoid
space, allowing CSF to drain. This procedure is often combined with ablation of the choroid plexus and is becoming
more commonly used in the US. It is particularly useful in less developed countries where access to consistent
neurosurgical care is often limited. In certain cases (eg, hydrocephalus caused by primary aqueductal stenosis), third
ventriculostomy may be adequate primary treatment.
A ventricular shunt that goes to the subgaleal space may be used in infants as a temporary measure for patients who
may not require a more permanent shunt.
Although some children do not need the shunt as they age, shunts are rarely removed because of the risk of bleeding
and trauma. Fetal surgery to treat congenital hydrocephalus has not been successful.
Shunt complications
The type of ventricular shunt used depends on the neurosurgeon’s experience, although ventriculoperitoneal shunts
cause fewer complications than ventriculoatrial shunts. Shunt complications include
Infection
Malfunction
Any shunt has a risk of infection. Manifestations include chronic fever, lethargy, irritability, headache, or a combination
and other symptoms and signs of increased intracranial pressure; sometimes redness becomes apparent over the
shunt tubing. Antibiotics effective against the organism infecting the shunt, which may include skin flora, are given,
and typically the shunt must be removed and replaced.
Shunts can malfunction because of a mechanical obstruction (typically blockage at the ventricular end) or because of
fracture of the tubing. In either case, intracranial pressure can increase, which, if sudden, can be a medical emergency.
Children present with headache, vomiting, lethargy, irritability, esotropia, or paralysis of upward gaze. Seizures may
occur. If the obstruction is gradual, more subtle symptoms and signs can occur, such as irritability, poor school
performance, and lethargy, which may be mistaken for depression. To assess shunt function, a shunt series (x-rays of
the shunt tubing) and neuroimaging studies are done. The ability to compress the bulb that is present on many shunt
systems is not a reliable sign of shunt function.
After the shunt is placed, head circumference and development are assessed, and imaging is done periodically.
Key Points
Hydrocephalus is usually caused by obstruction to the normal flow of CSF but can be due to impaired
resorption of CSF.
If the disorder occurs before the cranial sutures have fused, the head may be enlarged, with bulging
fontanelles.
Neurologic symptoms develop mainly if intracranial pressure increases; infants may have irritability,
high-pitched cry, vomiting, lethargy, and strabismus.
Diagnose using ultrasonography prenatally and in neonates; use MRI or CT for older children.
Treat with observation or serial lumbar punctures or a ventricular shunt procedure depending on the
etiology and severity and progression of symptoms.
© 2019 Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA)
https://www.msdmanuals.com/professional/pediatrics/congenital-neurologic-anomalies/hydrocephalus# 3/4
11/10/2019 Hydrocephalus - Pediatrics - MSD Manual Professional Edition
https://www.msdmanuals.com/professional/pediatrics/congenital-neurologic-anomalies/hydrocephalus# 4/4