Clinical Presentation of Hydrocephalus

The presentation of hydrocephalus differs in the case of the neonate and infant compared with the older child or adult.

Prior to closure of the cranial sutures and obliteration of the fontanelles, hydrocephalus results in disproportionate head growth. Thus, over the first 2-3 years of life, measurement of the occipito-frontal circumference and plotting this on a centile chart provides a simple and sensitive test. Wherever possible, sequential measurements (corrected for gestational age) should be obtained in order that the trend of head growth in relation to the centile lines can be demonstrated. Clinical symptoms are often subtle and include general irritability, poor feeding and slow attainment of milestones. In addition to head size, clinical signs include bulging of the fontanelle, separation of the cranial sutures, prominence of scalp veins and sun-setting of the eyes. This latter clinical sign is attributed to pressure on the mid-brain tectum by CSF in the supra-pineal recess. Papilloedema can be difficult to diagnose in the infant and indeed is not uncommonly absent in infantile hydrocephalus and so is an unreliable sign in this context.

In older children and adults, the classical symptom complex of raised intracranial pressure, headache, vomiting and drowsiness is more likely to herald an underlying diagnosis of hydrocephalus. Where hydrocephalus has developed insidiously, cognitive impairment, poor concentration and behavioural changes occur. Visual obscurations and papilloedema are more common than in the younger age group.

In both groups of patients, the presence of bradycardia, hypertension and irregularities in breathing pattern imply critical elevation of intracranial pressure and should be treated promptly.

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