eMedicine Specialties > Physical Medicine and Rehabilitation > Traumatic Brain Injury

Posttraumatic Hydrocephalus: Differential Diagnoses & Workup

Author: Percival H Pangilinan Jr, MD, Clinical Instructor and Consulting Staff, Department of Physical Medicine and Rehabilitation, University of Michigan Health System.
Coauthor(s): Brian M Kelly, DO, Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Michigan Medical School; Assistant Program Director, Residency Training Program, Consulting Staff, Service Chief 6A, Inpatient Rehabilitation Services, University of Michigan Health System; Joseph E Hornyak IV, MD, PhD, Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Michigan Medical School; Consulting Staff, Medical Director of Human Performance Laboratory, Department of Physical Medicine and Rehabilitation, University of Michigan Medical Center; Scott Strum, MD, Director of Traumatic Brain Injury Service, Assistant Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center
Contributor Information and Disclosures

Updated: Feb 12, 2008

Differential Diagnoses

Stroke Motor Impairment

Other Problems to Be Considered

Intracranial bleeding
Electrolyte imbalance
Adverse effects of medications
Hypoxia
Infection
Tumors
Stroke
Seizures
Uremia
Encephalopathy
Dementia

Workup

Laboratory Studies

  • Urine analysis and culture - Evaluate for urinary tract infections.
  • Complete blood count (CBC) with differential - Evaluate for infection and anemia.
  • Metabolic profile - Evaluate for electrolyte abnormalities, including syndrome of inappropriate secretion of antidiuretic hormone (SIADH), cerebral salt wasting, calcium deficiency, hypoglycemia, hyperglycemia, and encephalopathy (uremic or hepatic).
  • Thyroid-stimulating hormone (TSH), free T4 - Evaluate for hypothyroidism or hyperthyroidism.
  • Arterial blood gas level - Assess oxygenation and acid/base balance.
  • Serum medication levels - Measure medication levels if toxicity suspected.

Imaging Studies

  • Noncontrast CT scan of the brain is one of the most commonly used diagnostic modalities.
    • The progressive enlargement of the ventricular system shown on repeat computed tomography (CT) scans is the key to the diagnosis of PTH.6
    • CT scans may show enlarged lateral ventricles, effaced cerebral sulci, and dilation on ventricles proximal to an obstruction.4
    • Periventricular edema may occur in white matter, particularly around the frontal horns.4
    • Sulcal enlargement with ventricular enlargement suggests atrophy and hydrocephalus ex vacuo rather than hydrocephalus.4
    • Large cisterns and focal regions of encephalomalacia suggest atrophy.5
  • Magnetic resonance imaging (MRI) is another method of diagnostic evaluation.19
  •     MRI is more useful in the evaluation of injury to structures in the posterior fossa, including cerebral aqueduct stenosis and cerebellar tonsil herniation.20
  •     It is the neuroimaging study of choice in patients with NPH.20
  •     MRI may be more useful than CT scanning in the identification of other neurologic disorders, especially cerebrovascular disease.17

Mazzini studied another imaging technique, single-photon emission CT (SPECT).7 Mazzini found that SPECT had higher sensitivity than MRI or CT scanning in the demonstration of temporal lobe abnormality secondary to PTH.

Other Tests

  • Radionuclide cisternography:4
    • Radioiodinated serum albumin (RISA) injected into the subarachnoid space by way of lumbar puncture (LP) can normally be detected in the cisterna magna, basal cisterns, and subtentorial subarachnoid space within 6 hours, with little accumulation in the ventricular system. In NPH, RISA accumulates in the ventricular system with delayed pericerebral diffusion.
    • Cisternography is usually normal in hydrocephalus ex vacuo.
  • Although debate exists, cisternography may be a useful adjunct to CT scanning of the brain.

Procedures

  • CSF tap test
    • This test is an LP with manometry and CSF removal.
    • Imaging of the brain should be performed before initiating the LP. The risk of cerebral herniation associated with the LP is increased in patients with greatly elevated ICP.
    • The CSF tap test may be a useful predictor of the potential benefits of shunting.  Kim (2005) found that symtomatic improvement after lumbar drainage has a significant role in predicting the result of shunting.
    • CSF pressure is normally 110 mm water. Shunting may help if the pressure is 135-275 mm water, and it does help if the pressure is greater than 275 mm water.
    • Cognitive and physical functions are assessed before and after the removal of 50 mL of CSF. Improvement suggests that shunting may be beneficial.

More on Posttraumatic Hydrocephalus

Overview: Posttraumatic Hydrocephalus
Differential Diagnoses & Workup: Posttraumatic Hydrocephalus
Treatment & Medication: Posttraumatic Hydrocephalus
Follow-up: Posttraumatic Hydrocephalus
References
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References

  1. Bontke CF. Medical complications related to traumatic brain injury. Phys Med Rehabil: State Art Rev. 1989;3:43-58.

  2. Narayan RJ, Gokaslan ZL, Bontke CF. Neurologic sequelae of head injury. In: Rosenthal M, ed. Rehabilitation of the Adult and Child With Traumatic Brain Injury. 2nd ed. Philadelphia, Pa: Davis; 1990:94-106.

  3. Stein S, Schrader P. Neurologic sequelae. Phys Med Rehabil: State Art Rev. 1990;4:543-57.

  4. Katz RT, Brander V, Sahgal V. Updates on the diagnosis and management of posttraumatic hydrocephalus. Am J Phys Med Rehabil. Apr 1989;68(2):91-6. [Medline].

  5. Guyot LL, Michael DB. Post-traumatic hydrocephalus. Neurol Res. Jan 2000;22(1):25-8. [Medline].

  6. Groswasser Z, Cohen M, Reider-Groswasser I, et al. Incidence, CT findings and rehabilitation outcome of patients with communicative hydrocephalus following severe head injury. Brain Inj. Oct-Dec 1988;2(4):267-72. [Medline].

  7. Mazzini L, Campini R, Angelino E, et al. Posttraumatic hydrocephalus: a clinical, neuroradiologic, and neuropsychologic assessment of long-term outcome. Arch Phys Med Rehabil. Nov 2003;84(11):1637-41. [Medline].

  8. Dandy WE, Blackfan KD. Internal hydrocephalus: an experimental, clinical, and pathological study. Am J Dis Child. 1914;8:406.

  9. Adams RD, Victor M. Disturbances of cerebrospinal fluid and its circulation, including hydrocephalus and meningeal reactions. In: Principles of Neurology. 4th ed. New York, NY: McGraw-Hill Information Services Co; 1989:623-35.

  10. Portnoy HD, Chopp M, Branch C, et al. Cerebrospinal fluid pulse waveform as an indicator of cerebral autoregulation. J Neurosurg. May 1982;56(5):666-78. [Medline].

  11. Kaye AH, Laws ER, eds. Brain Tumors: An Encyclopedic Approach. 2nd ed. New York, NY: Churchill Livingstone; 2001:205.

  12. Mori K, Shimada J, Kurisaka M, et al. Classification of hydrocephalus and outcome of treatment. Brain Dev. Sep-Oct 1995;17(5):338-48. [Medline].

  13. Kim SW, Lee SM, Shin H. Clinical Analysis of Post-Traumatic Hydrocephalus. J Korean Neursurg Soc. 2005;38:211-214.

  14. Long DF. Diagnosis and management of intracranial complications in traumatic brain injury rehabilitation. In: Horn LJ, Zasler ND, eds. Medical Rehabilitation of Traumatic Brain Injury. Philadelphia, Pa: Hanley & Belfus; 1996:333-62.

  15. Paoletti P, Pezzotta S, Spanu G. Diagnosis and treatment of post-traumatic hydrocephalus. J Neurosurg Sci. Jul-Sep 1983;27(3):171-5. [Medline].

  16. Wostyn P, Audenaert K, De Deyn PP. Alzheimer's disease-related changes in diseases characterized by elevation of intracranial or intraocular pressure. Clin Neurol Neurosurg. Feb 2008;110(2):101-9. [Medline].

  17. Factora R, Luciano M. Normal pressure hydrocephalus: diagnosis and new approaches to treatment. Clin Geriatr Med. Aug 2006;22(3):645-57. [Medline].

  18. Tian HL, Xu T, Hu J, et al. Risk factors related to hydrocephalus after traumatic subarachnoid hemorrhage. Surg Neurol. Aug 16 2007;[Medline].

  19. Nasel C, Gentzsch S, Heimberger K. Diffusion-weighted magnetic resonance imaging of cerebrospinal fluid in patients with and without communicating hydrocephalus. Acta Radiol. Sep 2007;48(7):768-73. [Medline].

  20. Graff-Radford NR. Normal pressure hydrocephalus. Neurol Clin. Aug 2007;25(3):809-32, vii-viii. [Medline].

  21. Wu Y, Green NL, Wrensch MR, et al. Ventriculoperitoneal shunt complications in California: 1990 to 2000. Neurosurgery. Sep 2007;61(3):557-62; discussion 562-3. [Medline].

  22. Bontke CF, Zasler ND, Boake C. Rehabilitation of the head-injured patient. In: Narayan RK, Wilberger JE, Povlishock JT, eds. Neurotrauma. New York, NY: McGraw-Hill; 1996:841-58.

  23. Tribl G, Oder W. Outcome after shunt implantation in severe head injury with post-traumatic hydrocephalus. Brain Inj. Apr 2000;14(4):345-54. [Medline].

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Further Reading

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Keywords

posttraumatic hydrocephalus, PTH, hydrocephalus, traumatic brain injury, TBI, head injury, noncommunicating hydrocephalus, obstructive hydrocephalus, communicating hydrocephalus, nonobstructive hydrocephalus, normal pressure hydrocephalus, NPH

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Contributor Information and Disclosures

Author

Percival H Pangilinan Jr, MD, Clinical Instructor and Consulting Staff, Department of Physical Medicine and Rehabilitation, University of Michigan Health System.
Percival H Pangilinan Jr, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Coauthor(s)

Brian M Kelly, DO, Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Michigan Medical School; Assistant Program Director, Residency Training Program, Consulting Staff, Service Chief 6A, Inpatient Rehabilitation Services, University of Michigan Health System
Brian M Kelly, DO is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Osteopathic Association, American Osteopathic College of Physical Medicine and Rehabilitation, and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Joseph E Hornyak IV, MD, PhD, Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Michigan Medical School; Consulting Staff, Medical Director of Human Performance Laboratory, Department of Physical Medicine and Rehabilitation, University of Michigan Medical Center
Joseph E Hornyak IV, MD, PhD is a member of the following medical societies: American Academy of Cerebral Palsy and Developmental Medicine, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Scott Strum, MD, Director of Traumatic Brain Injury Service, Assistant Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University Medical Center
Scott Strum, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Medical Editor

Elizabeth A Moberg-Wolff, MD, Associate Professor and Pediatric PM&R Fellowship Director, Department of Physical Medicine and Rehabilitation, Medical College of Wisconsin; Program Director, Tone Management and Mobility, Department of Physical Medicine and Rehabilitation, Children's Hospital of Wisconsin
Elizabeth A Moberg-Wolff, MD is a member of the following medical societies: American Academy of Cerebral Palsy and Developmental Medicine and American Academy of Physical Medicine and Rehabilitation
Disclosure: Medtronic Neurological Grant/research funds Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Kat Kolaski, MD, Assistant Professor, Departments of Orthopedic Surgery and Pediatrics, Wake Forest University School of Medicine
Kat Kolaski, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine and American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center
Disclosure: Nothing to disclose.

Chief Editor

Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center
Consuelo T Lorenzo, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

 
 
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