Posttraumatic Hydrocephalus Workup
- Author: Percival H Pangilinan, Jr, MD; Chief Editor: Consuelo T Lorenzo, MD more...
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- 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.
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- 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.
- CT scans may show enlarged lateral ventricles, effaced cerebral sulci, and dilation on ventricles proximal to an obstruction.
- Periventricular edema may occur in white matter, particularly around the frontal horns.
- Sulcal enlargement with ventricular enlargement suggests atrophy and hydrocephalus ex vacuo rather than hydrocephalus.
- Large cisterns and focal regions of encephalomalacia suggest atrophy.
- Magnetic resonance imaging (MRI) is another method of diagnostic evaluation.
- MRI is more useful in the evaluation of injury to structures in the posterior fossa, including cerebral aqueduct stenosis and cerebellar tonsil herniation.
- It is the neuroimaging study of choice in patients with NPH.
- MRI may be more useful than CT scanning in the identification of other neurologic disorders, especially cerebrovascular disease.
Mazzini studied another imaging technique, single-photon emission CT (SPECT). Mazzini found that SPECT had higher sensitivity than MRI or CT scanning in the demonstration of temporal lobe abnormality secondary to PTH.
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- Radionuclide cisternography:
- 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.
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- 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.
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