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
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