CASE PRESENTATION

PGI QURRATAINI I. BALOCANG

OBJECTIVES
General
To present a case of a 6 months old, male who
came in due to increasing head size

Specific
To be able to discuss the patients condition, its
characteristics and management

GENERAL DATA

M.B.
6 months old
Male
Catholic
Filipino
Purok Tala, Brgy. Salawag, Quezon, Bukidnon
Admitted for the first time at NMMC

CHIEF COMPLAINT
HEAD

ENLARGEMENT

HISTORY OF PRESENT
ILLNESS
Patient was born to a 20 year old G1P1(1001) mother via
cesarean section due to cephalopelvic disproportion in a
hospital at Cotabato City.

2months PTA, mother sought consult at German Doctors

Hospital. He was
then subsequently referred to our
institution for further evaluation and management.
CT Scan-Brain Plain was done which revealed Severe
Hydrocephalus; Consider Acqueduct Stenosis, mother was
then advised for surgery thus admitted.

PAST MEDICAL
HISTORY
No
No
No
No

known previous infections

known allergies to food and drugs
history of previous admission
history of surgical operation

BIRTH HISTORY
ANTENATAL

Prenatal Check-ups started at 12 wks AOG at their Local

Health Center. Mother was given 5 TT doses. No maternal
illnesses such as UTI, bleeding, preeclampsia/eclampsia
and other infections noted during the course of
pregnancy.

NATAL

Patient was delivered through CS assisted by a doctor.

No resuscitation done. Birth weight at 4kg and head
circumference was unrecalled.

NEONATAL

Patient was born with a good cry and pinkish color.

Noted was the patients unusually large head. Patient had
no history of fever or convulsions.

FAMILY
HISTORY
(-) Hypertension
(-)
(-)
(-)
(-)

Diabetes mellitus
Asthma
Cancer
Familial megalencephaly

PSYCHOSOCIAL
Father E.B., 22-year old, Laborer
Mother J.B., 20-year old, Unemployed
HISTORY
1/1

PHYSICAL
EXAMINATION

GENERAL APPEARANCE:
Patient is fairly nourished, conscious, with good cry and activity, afebrile,
not in respiratory distress
VITAL SIGNS:

Temp= 36.8 C
HR= 120 bpm
RR= 29 cpm
Weight= 10.8 kg
Height= 85 cm

 SKIN: no jaundice , no pallor good skin turgor, no

rashes and skin discoloration
HEENT: Head circumference-70cm; prominent
head veins, bulging anterior fontanel, sunset
eyeballs, anicteric sclerae, pinkish palpebral conjuctivae,
isocoric, pupils equally reactive to light & accommodation, no
discharges, ears no discharges or lesions, Septum is in midline,
no masses, discharges or sinus tenderness, moist lips and oral
mucosa, no masses, no tonsillar enlargement or exudates

NECK: supple, (-) rigidity, (-)lymphadenopathy

CHEST & LUNGS:

symmetrical; equal chest expansion; no retractions no rales/wheezes

CARDIOVASCULAR:
distinct heart sounds; regular rate rhythm; no murmurs

ABDOMEN
protuberant, soft, normoactive bowel sounds

EXTREMITIES
CRT <2 secs, strong pulses, full ROM

WORKING IMPRESSION
Congenital Hydrocephalus

SALIENT FEATURES
HISTORY

PHYSICAL FINDINGS
Head circumference of 70cm (35cm)
Bulging anterior and posterior fontanels
Sunset eyes

DIFFERENTIALS
RULED IN

RULED OUT

Familial megalencephaly
Macrocephaly

Osteogenesis imperfecta

Macrocephaly

Neurofibromatosis

Macrocephaly

No familial history of large

heads in the family
No bone fragility
No caf-au-lait spots
No first degree relative with
neurofibromatosis

CASE
DISCUSSION

HYDROCEPHALUS
1Excess CSF in the brain that results in
enlarged ventricles
2Disturbance of CSF formation, flow or
absorption leading to an increase in volume
occupied by this fluid in the CNS.
3Abnormal condition consisting of an
increased volume of CSF along with distension
of CSF spaces
1.Shwartz Principle of Surgery 8th Ed

2.Medscape 3. Surgical Recall 6th Ed

VENTRICULAR SYSTEM

CEREBROSPINAL
FLUID

Daily production
Normal volume

500 mL
120-150 mL ADULT
50 mL INFANT

Normal CSF production 0.20-0.35 mL/min

1.Shwartz Principle of Surgery 8th Ed

2. Surgical Recall 6th Ed 3. Medscape

HYDROCEPHALUS

Congenital- may be due to intrauterine infection stenosis

of aqueduct, chiari malformations, myelomeningocele,
and intrauterine infections
Acquired- may result from occlusion or arachnoid
granulations by meningitis or subarachnoid hemmorhage
or occlusion of CSF pathways by adjacent tumors

INCIDENCE
Shwartz Principle of Surgery 8th Ed

Medscape

3 per 1,000 live births

CAUSES
Increased production of CSF
Decreased absorption of CSF
Obstruction of normal flow of CSF (90% of case)

Surgical Recall 6th Ed

CLINICAL
MANIFESTATIONS

headache, nausea, vomiting, ataxia, increasing head

circumference exceeding norms for age
INFANTS
poor feeding, irritability, reduced activity, vomiting
head enlargement, dysjunction of sutures, dilated
scalp veins, tense fontanelle, setting-sun sign,
increased limb tone
Surgical Recall 6th Ed Medscape

DIAGNOSIS
CT scan
MRI
measurement of head
circumference

Surgical Recall 6th Ed

MANAGEMENT
SURGERY - Treatment of choice
Direct

removal of source of obstruction

(neoplasm, cyst, or hematoma)

Most require

shunt procedure

to drain CSF from ventricles to extracranial area; usually peritoneum (VP shunt), or
right atrium (VA shunt) for absorption.

Shwartz Principle of Surgery 8th Ed

VP shunt
Used in neonates and young infants
Greater allowance for excess tubing;
which minimizes number of revisions
needed as child grows

VA shunt

Reserved for older children who

have attained most of somatic
growth, or children with abdominal
pathology.
Contraindicated in children
cardiopulmonary disease or
elevated CSF protein.

with
with

PROGNOSIS

Long term outcome is related directly to the cause of

hydrocephalus
Develop permanent hydrocephalus requiring shunt
50% large intraventricular hemorrhage
20% s/p removal of a posterior fossa in children

50% mortality IF UNTREATED

survivors show decreased IQ (mean 69);
neurologic sequelae: ataxia, paraparesis, visual decits

Medscape

Surgical Recall 6th Ed

THANK YOU