In this episode, we discuss the case of a 15-year-old girl who presents with progressive headache, nausea, vomiting, and difficulty ambulating. Her condition rapidly evolves into altered mental status and severe hydrocephalus, leading to a compelling discussion about the evaluation, diagnosis, and management of hydrocephalus in pediatric patients.

We break down the case into key elements:

A comprehensive look at acute hydrocephalus, including its pathophysiology and causes
Epidemiological insights, clinical presentation, and diagnostic approaches
Management strategies, including temporary and permanent CSF diversion techniques
A review of complications related to shunts and endoscopic third ventriculostomy

Key Case Highlights:

Patient Presentation:
A 15-year-old girl with a 3-day history of worsening headaches, nausea, vomiting, and difficulty walking
Altered mental status and bradycardia upon PICU admission
CT scan revealed severe hydrocephalus without a clear mass lesion
Management Steps in the PICU:
Hypertonic saline bolus improved her mental status and pupillary reactions
Neurosurgery consultation recommended MRI and close neuro checks
Initial management included dexamethasone, keeping the patient NPO, and hourly neuro assessments
Differential Diagnosis:
Obstructive (non-communicating) vs. non-obstructive (communicating) hydrocephalus
Consideration of alternative diagnoses like intracranial hemorrhage and idiopathic intracranial hypertension

Episode Learning Points:

Hydrocephalus Overview:
Abnormal CSF buildup in the ventricles leading to increased intracranial pressure (ICP)
Key distinctions between obstructive and non-obstructive types

Epidemiology and Risk Factors:

Congenital causes include genetic syndromes, neural tube defects, and Chiari malformations
Acquired causes: post-hemorrhagic hydrocephalus (e.g., from IVH in preemies), infections like TB meningitis, and brain tumors

Clinical Presentation:

Infants: Bulging fontanelles, sunsetting eyes, irritability
Older children: Headaches, vomiting, papilledema, and gait disturbances

Management Framework:

Temporary CSF diversion via external ventricular drains (EVD) or lumbar catheters
Permanent interventions include VP shunts and endoscopic third ventriculostomy (ETV)

Complications of Shunts and ETV:

Shunt infections, malfunctions, over-drainage, and migration
ETV-specific risks, including delayed failure years post-procedure

Clinical Pearl:

Communicating hydrocephalus involves symmetric ventricular enlargement and is often linked to inflammatory or post-treatment changes affecting CSF reabsorption.

Hosts’ Takeaway Points:

Dr. Pradip Kamat emphasizes the importance of timely recognition and intervention in hydrocephalus to prevent complications like brain herniation.
Dr. Rahul Damania highlights the need for meticulous neurological checks in PICU patients and an individualized approach to treatment.

Resources Mentioned:

Hydrocephalus Clinical Research Network guidelines.
Recent studies on ETV outcomes in pediatric populations.

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Acute Hydrocephalus in the PICU

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