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Hydrocephalus – Causes, Symptoms and Treatment

Hydrocephalus is a condition in which excess cerebrospinal fluid builds up in the brain ventricles, increasing pressure inside the skull and potentially causing brain damage.

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Things worth knowing about "Hydrocephalus"

Hydrocephalus is a condition in which excess cerebrospinal fluid builds up in the brain ventricles, increasing pressure inside the skull and potentially causing brain damage.

What is Hydrocephalus?

Hydrocephalus – sometimes informally called water on the brain – is a neurological condition characterized by an abnormal accumulation of cerebrospinal fluid (CSF) within the ventricles (fluid-filled cavities) of the brain. This buildup causes the ventricles to enlarge and raises intracranial pressure, which can compress brain tissue and lead to serious neurological damage if left untreated.

Under normal circumstances, CSF is continuously produced, circulates through the brain and spinal cord, and is reabsorbed into the bloodstream. Hydrocephalus develops when this balance is disrupted – either due to a blockage in CSF flow, impaired reabsorption, or rarely, overproduction of fluid.

Causes

Hydrocephalus can be classified into several types based on its underlying cause:

Obstructive (non-communicating) hydrocephalus: A physical blockage prevents CSF from flowing through the ventricular system. Common causes include tumors, cysts, congenital narrowing (e.g., aqueductal stenosis), or inflammation.
Communicating hydrocephalus: CSF can still flow between ventricles but is not adequately reabsorbed, often following meningitis, subarachnoid hemorrhage, or head trauma.
Normal pressure hydrocephalus (NPH): A form mainly seen in older adults where ventricles are enlarged but CSF pressure remains within a normal range.
Congenital hydrocephalus: Present at birth, often associated with neural tube defects such as spina bifida or other developmental abnormalities.

Symptoms

Symptoms vary depending on the age of onset and the rate of CSF accumulation:

Infants and Young Children

Abnormally rapid increase in head circumference
Bulging or tense fontanelle (soft spot on the skull)
Prominent scalp veins
Downward deviation of the eyes (known as sunset sign)
Irritability, lethargy, and poor feeding

Older Children and Adults

Persistent headaches, often worse in the morning
Nausea and vomiting
Visual disturbances including blurred or double vision
Difficulty walking and balance problems
Memory loss and difficulty concentrating
In NPH: classic triad of gait disturbance, urinary incontinence, and cognitive decline (dementia)

Diagnosis

Diagnosis is primarily established through neuroimaging and clinical evaluation:

Magnetic Resonance Imaging (MRI): The preferred method for detailed visualization of ventricular size, CSF flow patterns, and potential underlying causes.
Computed Tomography (CT) scan: Widely available and useful for initial or emergency assessment of ventricular enlargement.
Ultrasound: Used in newborns and infants while the fontanelle remains open, allowing non-invasive imaging of the brain.
Lumbar puncture: CSF pressure measurement and fluid analysis, particularly useful in the evaluation of NPH.

Treatment

Treatment aims to restore normal CSF pressure and prevent further neurological injury. The main therapeutic options include:

Shunt Implantation

A ventriculoperitoneal (VP) shunt is the most commonly used surgical procedure. A thin, flexible tube is implanted to divert excess CSF from the brain ventricles into the abdominal cavity, where it is safely reabsorbed. Other shunt types include ventriculoatrial shunts, which drain fluid into the heart.

Endoscopic Third Ventriculostomy (ETV)

In this minimally invasive procedure, a small opening is created in the floor of the third ventricle using an endoscope, allowing CSF to bypass the obstruction and flow freely. ETV is particularly effective for obstructive hydrocephalus.

Treatment of Underlying Causes

When hydrocephalus is secondary to an identifiable cause – such as a brain tumor, infection, or hemorrhage – treating the root cause may help normalize CSF dynamics.

Medication

Drugs such as acetazolamide or furosemide may temporarily reduce CSF production but are generally not a long-term solution and are mainly used as a bridge to surgical treatment.

Prognosis

The outlook for individuals with hydrocephalus depends on the underlying cause, severity, and how quickly treatment is initiated. With early diagnosis and appropriate management, many patients can live full and productive lives. However, untreated hydrocephalus can lead to permanent neurological disability or be life-threatening.

References

Rekate HL. A contemporary definition and classification of hydrocephalus. Seminars in Pediatric Neurology, 2009; 16(1):9-15.
Kahle KT, Kulkarni AV, Limbrick DD, Warf BC. Hydrocephalus in children. The Lancet, 2016; 387(10020):788-799.
National Institute of Neurological Disorders and Stroke (NINDS). Hydrocephalus Fact Sheet. U.S. Department of Health and Human Services. www.ninds.nih.gov

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