Neurosurgery for Hydrocephalus Clinical Presentation

Updated: Jun 23, 2020
  • Author: Herbert H Engelhard, III, MD, PhD, FACS, FAANS; Chief Editor: Brian H Kopell, MD  more...
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History and Physical Examination

The various types of hydrocephalus can present differently in different age groups.

Acute hydrocephalus typically presents with headache, gait disturbance, vomiting, and visual changes. In infants, irritability or poor head control can be early signs of hydrocephalus. When the third ventricle dilates, the patient can present with Parinaud syndrome (upgaze palsy with a normal vertical Doll response) or the setting sun sign (Parinaud syndrome with lid retraction and increased tonic downgaze).

Occasionally, a focal deficit, such as sixth nerve palsy, can be the presenting sign. Papilledema is often present, though it may lag behind symptomatology. Infants present with bulging fontanelles, dilated scalp veins, and an increasing head circumference. When advanced, hydrocephalus presents with brainstem signs, coma, and hemodynamic instability.

Normal-pressure hydrocephalus has a very distinct symptomatology. The patient is older and presents with progressive gait apraxia, incontinence, and dementia. This triad of symptoms defines normal-pressure hydrocephalus.