Note: - skull size and suture width.

- evidence of chronic raised pressure - erosion of the posterior clinoids.

- associated defects - platybasia, basilar invagination. CT scan

The pattern of ventricular enlargement helps determine the cause, i.e.


3rd ventricular dilatation normal 4th / ventricle

deviated or absent 4th ventricle suggests aqueduct < stenosis, suggests a posterior fossa mass.

generalised -dilatation suggests a communicating hydrocephalus suggests a communicating hydrocephalus

Periventricular lucency (if present) suggests raised CSF pressure.

(Wide sulci suggests ventricular dilatation is due to an atrophic process.)

Dilated 3rd ventricle

Dilated lateral ventricle (temporal horns)

Normal 4th ventricle

Ultrasonography through the anterior fontanelle, usefully demonstrates ventricular enlargement in infants but provides less precise information than CT scanning. MRI shows similar ventricular expansion, but may more clearly demonstrate periventricular lucency or a neoplastic cause of the obstruction. ICP monitoring: used to investigate patients with suspected normal pressure hydrocephalus and designed to predict the likelihood of a beneficial response to shunting (see page 127).

Developmental assessment and psychometric analysis detect impaired cerebral function and provide a baseline for future comparison.


Acute ^ ventricular drainage or deterioration ventriculo-peritoneal (VP) (or ventriculoatrial (VA) shunt if peritoneal adhesions) lumbar puncture - if communicating hydrocephalus, e.g. following subarachnoid haemorrhage. Gradual VP shunt (lumboperitoneal shunts are occasionally used for deterioration communicating hydrocephalus).

removal of a mass lesion if present - this may obviate the need for a shunt. 'Arrested hydrocephalus' - symptomless ventricular dilatation requires no treatment, but regular developmental or psychometric assessment ensures no 362 ill effects develop from this potentially unstable state.

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