Hydrocephalus of the brain: causes, symptoms and diagnosis. Treatment of hydrocephalus in Moscow

Hydrocephalus in adults is a pathological condition that is characterized by excessive accumulation of cerebrospinal fluid in the cerebrospinal fluid spaces of the brain. Hydrocephalus can be an independent disease or a consequence of various pathological processes in the brain. Long-term hydrocephalus can lead to disability or death. Effective treatment of hydrocephalus in adults is carried out by neurologists at the Yusupov Hospital.

Hydrocephalus of the brain in the elderly

Hydrocephalus in older people occurs when excess fluid accumulates in the brain due to impaired production or absorption of cerebrospinal fluid or blockage of the pathways through which cerebrospinal fluid flows out. Excessive cerebrospinal fluid can press brain tissue against the skull, causing brain tissue damage. At the Yusupov Hospital, professors and doctors of the highest category make diagnoses using modern research methods. Neurologists determine the cause and extent of the disease and apply individual treatment regimens to patients.

The substance of the brain and spinal cord is constantly washed by cerebrospinal fluid. It protects the brain from damage and provides nutrients. The circulation of cerebrospinal fluid occurs in the subarachnoid space between the pia mater and the choroid along the surface of the cerebral hemispheres and the cerebellum. Under the base of the brain there are cisterns in which cerebrospinal fluid accumulates. They connect to the subarachnoid space.

Liquor is concentrated in the three ventricles of the brain. They communicate with the fourth ventricle, which is located between the brain stem and the cerebellum. From the fourth ventricle, cerebrospinal fluid enters the spinal canal through two lateral openings and spreads down to the lumbar region. When the cerebrospinal fluid outflow pathways are blocked, hydrocephalus develops.

In the presence of increased intracranial pressure, doctors at the Yusupov Hospital prescribe diacarb, mannitol and mannitol to older people in combination with furosemide or lasix. These drugs have a diuretic effect, removing excess fluid from the body. Diacarb temporarily blocks the production of cerebrospinal fluid. To correct potassium levels in the body, use asparkam or panangin. Nutrition of brain tissue in elderly patients improves after using Cavinton, Actovegin, Cerebrolysin, and Semax.

Neurosurgeons at partner clinics of the Yusupov Hospital perform the following endoscopic operations on elderly people:

aqueductoplasty;
endoscopic ventriculocisternostomy of the floor of the third ventricle;
removal of intraventricular brain tumor;
septostomy;
endoscopic installation of a shunt system.

After the operation, the patient's condition improves, and neurological symptoms reverse. Elderly people with hydrocephalus restore their ability to self-care and adapt to social life.

Hydrocephalus - symptoms and treatment

To date, the method of surgical treatment of hydrocephalus has proven its effectiveness.

Two types of surgical interventions are used: liquor shunting and neuroendoscopy. Such operations are performed by a neurosurgeon, i.e. a surgeon specializing in the treatment of diseases of the brain, spinal cord and peripheral nervous system.

CSF shunt surgery

In a CSF shunt, a thin tube called a shunt is inserted into a ventricle of the brain. Excess cerebrospinal fluid contained in the brain flows through the shunt to another anatomical region of the human body.

When installing the drainage end of the system into the abdominal cavity, the shunt is called ventriculoperitoneal . In this case, excess cerebrospinal fluid entering the abdominal cavity is absorbed into the bloodstream.

When the draining end of the system is installed into the chamber of the heart (usually the right atrium), the shunt is called ventriculoatrial . They are typically implanted in children because growth has less impact on their functioning and requires replacement less often, unlike ventriculoperitoneal shunts.

Lumboperitoneal are rarely used . They drain cerebrospinal fluid from the subarachnoid space of the lumbar spinal cord into the abdominal cavity.

In the system of tubes through which cerebrospinal fluid flows from the brain, there is a valve with a given throughput. Depending on the cerebrospinal fluid pressure, an appropriate valve is selected for the patient before the operation, which makes it possible to control the outflow of cerebrospinal fluid into the abdominal cavity, i.e. having a given capacity. The neurosurgeon planning surgery determines the pressure of the cerebrospinal fluid in the brain and selects the appropriate valve. It usually appears as a raised “bump” under the scalp.

Today, two types of valves are used:

with given (preset) parameters that have a certain throughput for cerebrospinal fluid;
adjustable magnetic valves. When choosing such valves, the attending physician, using special equipment, can remotely, without making additional incisions, change the pressure of the valve and achieve an optimal clinical result, eliminating such adverse side effects as insufficient or excessive drainage of the cerebrospinal fluid.

CSF bypass operations are performed under general anesthesia and take from one to two hours. After surgery, patients usually remain in the hospital for several days.

If the outflow of cerebrospinal fluid through the shunt is disrupted or infection occurs, repeated surgery may be required.

Endoscopic ventriculostomy of the third ventricle

This operation is an alternative to liquor shunt surgery. Instead of installing a shunt, the surgeon creates a hole in the lower wall of the third ventricle and creates a bypass for the outflow of cerebrospinal fluid to the surface of the brain, where its unhindered absorption occurs.

This operation is not universal for all patients with hydrocephalus, but can be used to block the cerebrospinal fluid pathways - occlusive hydrocephalus. In this case, the cerebrospinal fluid flows through an artificially created hole - bypassing the clogged cerebrospinal fluid pathways.

The operation of endoscopic ventriculostomy of the third ventricle is performed under general anesthesia. The neurosurgeon makes a burr hole in the skull with a diameter of about 10 mm and uses an endoscope to examine the ventricles of the brain from the inside. An endoscope is a long, thin tube with a light source and a miniature video camera at the end.

Through the channel located inside the endoscope, it is possible to carry out special surgical instruments to perform operations on the deep structures of the brain. After installing the endoscope into the third ventricle, a hole is formed in its lower wall. Through the newly formed anastomosis, cerebrospinal fluid enters the subarachnoid space. After removing the endoscope, sutures are placed on the aponeurosis and skin. The duration of the operation is about one hour.

The risk of infectious complications is much lower after endoscopic surgery compared to cerebrospinal fluid shunting.

Endoscopic ventriculostomy of the third ventricle has no advantages over cerebrospinal fluid shunting in long-term follow-up. After endoscopic intervention, as well as after cerebrospinal fluid shunting, hydrocephalus can develop again, even several years after the operation.

Treatment of normal pressure hydrocephalus

In case of normal pressure hydrocephalus, which usually develops in older people, the condition can be improved by performing a cerebrospinal fluid shunt operation. Although not all patients with this diagnosis have surgical treatment that is effective.

Due to the risks associated with any surgery, specific tests (stopping lumbar drainage and/or performing a lumbar infusion test) are necessary to assess the potential benefit of surgery, which should outweigh the risk of adverse effects.

According to the literature, more than 80% of patients with normal pressure hydrocephalus who responded positively to preliminary testing reported significant improvement after ventriculoperitoneal shunting. Visible clinical improvement after surgery usually occurs within a few weeks or even months.

A timely and correct diagnosis is the key to successful treatment, even in patients who have suffered from hydrocephalus for several years.[1][7]

Symptoms of hydrocephalus

Hydrocephalus can be congenital or acquired. Depending on the mechanism of development, the following types of hydrocephalus in adults are distinguished:

occlusive hydrocephalus in adults - develops due to disruption of the flow of cerebrospinal fluid due to a block of the cerebrospinal fluid pathways by a blood clot, part of a tumor or adhesion;
open hydrocephalus - occurs due to impaired absorption into the venous system of the brain at the level of venous sinuses, pachyonic granulations, arachnoid villi, cells;
hypersecretory hydrocephalus - develops with excessive production of cerebrospinal fluid by the choroid plexuses of the ventricles.

Open hydrocephalus is called “communicating hydrocephalus of the brain in adults.” Replacement hydrocephalus of the brain in adults is one of the types of the disease. It is accompanied by a gradual decrease in the volume of brain matter and replacement of cerebrospinal fluid.

There are internal and external hydrocephalus. Internal hydrocephalus is characterized by excessive cerebrospinal fluid content in the ventricles. External hydrocephalus is characterized by excessive content of cerebrospinal fluid in the subarachnoid space while at the same time normal levels of its content in the ventricles.

Depending on the level of intracranial pressure, hydrocephalus in adults can be:

normotensive (cerebrospinal fluid pressure is normal);
hypertensive (cerebrospinal fluid pressure is increased);
hypotensive (low cerebrospinal fluid pressure).

Acute hydrocephalus develops within 3 days, chronic - from 3 weeks to 6 months or more.

Hydrocephalus in adults develops due to the following reasons:

infectious diseases of the brain and its membranes (encephalitis, meningitis, ventriculitis);
neoplasms of the brain stem, peri-brain structures or ventricles of the brain);
vascular pathology of the brain (subarachnoid and intraventricular hemorrhage as a result of rupture of improper connections of arteriovenous vessels or aneurysms);
encephalopathy (toxic, alcoholic);
malformations of the nervous system;
brain injuries and post-traumatic conditions.

Atrophic hydrocephalus develops against the background of the following diseases:

tumors of the ventricles and brain matter;
toxic and alcoholic encephalopathies;
infectious brain lesions (ventriculitis, encephalitis, meningitis);
vascular cerebral pathology, including rupture of an aneurysm and intraventricular and subarachnoid cerebral hemorrhages resulting from defects in arteriovenous connections;
pathologies of the development of the nervous system (Dandy-Walker syndrome, stenosis of the Sylvian aqueduct);
post-traumatic conditions and brain injuries.

In atrophic encephalopathy, cerebrospinal fluid fills the space formed inside the skull as a result of a decrease in brain volume. Atrophic hydrocephalus of the brain in elderly and senile people can develop against the background of impaired blood supply to the brain due to arterial hypertension, atherosclerosis of cerebral vessels, and diabetic angiopathy.

The clinical picture depends on the period of formation of hydrocephalus, the mechanism of development and the level of cerebrospinal fluid pressure. In acute and subacute occlusive hydrocephalus, patients complain of headache, more pronounced in the morning (especially after sleep), which is accompanied by nausea and vomiting, which brings relief. There is a feeling of pressure on the eyeballs from the inside, a feeling of “sand” in the eyes and a burning sensation. The pain is bursting in nature. Redness of the sclera may occur.

If the cerebrospinal fluid pressure increases, drowsiness occurs. This is a bad prognostic sign, as it indicates an increase in symptoms and threatens loss of consciousness. Vision may deteriorate and a feeling of “fog” may appear before the eyes. In the fundus, ophthalmologists detect congestive optic discs. If the patient is not provided with medical assistance, the content of cerebrospinal fluid and intracranial pressure will increase.

Subsequently, dislocation syndrome develops, a condition that threatens the patient’s life. When the midbrain is compressed, consciousness is rapidly depressed to the point of coma, upward gaze paresis, divergent strabismus, and reflex depression develop. When compression of the medulla oblongata occurs, swallowing is impaired, the voice changes to the point of loss of consciousness, breathing and cardiac activity are inhibited.

Communicating hydrocephalus of the brain in adults often has a chronic course. The disease develops gradually, several months after exposure to the provoking factor. Initially, the sleep cycle is disrupted, drowsiness or insomnia appears. Patients' memory deteriorates, fatigue and lethargy appear. As the disease progresses, cognitive impairment worsens, leading to dementia. Patients behave inappropriately and lose the ability to self-care.

With chronic hydrocephalus in adults, walking is impaired. The gait becomes unstable and slow. Then comes difficulty in starting to move and uncertainty when standing. The patient, in a sitting or lying position, can imitate riding a bicycle or walking. In a vertical position, this ability is instantly lost. The gait becomes “magnetic”. The patient seems to be glued to the floor, and, having moved from his place, he takes shuffling small steps on widely spaced legs or marks time. Increased muscle tone is detected. In advanced cases, muscle strength decreases and paresis appears in the lower extremities. Balance disorders progress, up to the inability to sit or stand independently.

Patients with chronic hydrocephalus may urinate more frequently, especially at night. Gradually, an imperative urge to urinate begins, requiring immediate emptying. Over time, urinary incontinence develops.

Moderate external hydrocephalus in an adult can be a primary or secondary disease. It develops after a stroke, meningitis, as a result of arterial hypertension, cancer pathology, instability of the cervical spine, cerebral atherosclerosis. Moderate external hydrocephalus is often asymptomatic and leads to brain hypoxia. Patients have the following signs of external hydrocephalus:

migraine-like headaches;
fast fatiguability;
nausea and vomiting;
hearing and vision impairment.

Minor hydrocephalus manifests itself with mild symptoms.

Symptoms of external hydrocephalus

The clinical picture in each specific case will be different, and the nature of the manifestation of the disease depends on the severity of the pathological process and the state of the central nervous system. Common symptoms are frequent headaches, blurred vision, nausea, vomiting, and weakness. By the way, pain is more localized in the frontoparietal region and in the area of the eyeballs. A person with dropsy experiences pain in the first half of the day, with sudden movements, coughing, sneezing, or severe physical exertion.

Symptoms may vary depending on the severity of the disease. Scientists distinguish 3 stages, and each has its own characteristics:

Mild external hydrocephalus. With a minimal amount of dropsy, the human body will try on its own to cope with such a problem as impaired circulation of the cerebrospinal fluid. In this case, you will feel a slight malaise, periodic dizziness, short-term darkening in the eyes, and a tolerable headache.

The middle stage of development of the disease. At this stage of the spread of the disease, symptoms appear intensely and are more pronounced. Due to an increase in intracranial pressure, severe headaches occur during physical activity, swelling of the optic nerve and facial tissues, increased fatigue, nervousness, depression, and surges in blood pressure.

Severe form of the disease. Signs of pathology in severe forms of external hydrocephalus are reduced to convulsive seizures, frequent fainting, a state of apathy, loss of intellectual abilities, memory loss and inability to care for oneself. Progressive dropsy can even lead to death, so there is no need to delay going to the doctor. It is better to do this at the first suspicion and a slight deterioration in health.

With chronic accumulation of cerebrospinal fluid, symptoms such as unsteady gait, paralysis of the upper and lower extremities, urinary incontinence, nighttime insomnia and daytime sleepiness, depressed mood, and a complex of psychoneurological disorders can be observed.

Diagnosis of hydrocephalus in adults

Doctors at the Yusupov Hospital diagnose hydrocephalus using computed tomography and magnetic resonance imaging. These methods make it possible to determine the size and shape of the ventricles, brain cisterns, and subarachnoid space. If doctors at a neurology clinic detect early signs of hydrocephalus on an MRI, they prescribe medication to stop the progression of the disease. X-ray of the cisterns at the base of the brain allows us to clarify the type of hydrocephalus and assess the direction of the cerebrospinal fluid flow.

Neurologists at the Yusupov Hospital use the following methods for diagnosing atrophic hydrocephalus:

magnetic resonance or computed tomography, which allows you to determine the size and shape of the cisterns of the brain, ventricles and subarachnoid space;
radiography of the tanks, with the help of which the type of hydrocephalus is clarified and the direction of the cerebrospinal fluid flow is determined;
diagnostic test spinal puncture with collection of 40-55 ml of cerebrospinal fluid, accompanied by a short-term improvement in the patient’s condition;
ultrasound examination of cerebral vessels to determine the state of arterial and venous blood flow.

After analyzing the results of a comprehensive study, individual treatment is prescribed. The tactics for managing patients with severe hydrocephalus are developed at a meeting of the expert council with the participation of professors and doctors of the highest category. Neurosurgeons determine indications for surgical intervention.

A trial diagnostic lumbar puncture with removal of 30-50 ml of cerebrospinal fluid is carried out to diagnose the disease. After the procedure, the patient’s condition temporarily improves due to the restoration of blood supply to ischemic brain tissue against the background of a decrease in intracranial pressure. In acute hydrocephalus, lumbar puncture is not performed due to the high risk of brainstem herniation and the development of dislocation syndrome.

To clarify the diagnosis, neurologists at the Yusupov Hospital prescribe craniography, ultrasound, and angiography. The results of the examination are discussed at a meeting of the expert council, where tactics for managing a patient with hydrocephalus are developed.

Treatment of hydrocephalus in adults

How to treat hydrocephalus of the brain in adults? Neurologists at the Yusupov Hospital treat the initial stages of hydrocephalus with medication.

Drug treatment of hydrocephalus in adults is carried out using the following drugs:

reducing intracranial pressure and promoting the removal of excess fluid. Such drugs include Diacarb, Mannitol and Mannitol in combination with Lasix and Furosemide. In this case, the patient must be prescribed the drug “Asparkam”, which corrects the level of potassium in the body.
improving nutrition of brain tissue. This group includes Cavinton, Gliatilin, Cortexin, Choline, Actovegin, Semax, etc.

In case of acute hydrocephalus, craniotomy is performed and external drains are applied to ensure the outflow of excess fluid. Medicines are administered through the drainage system. Brain shunting for hydrocephalus in adults is a type of surgical intervention in which excess cerebrospinal fluid is removed into the natural cavities of the human body using a complex system of catheters and valves. In the cavities, cerebrospinal fluid is freely absorbed.

To treat hydrocephalus in adults, neurosurgeons use a low-traumatic neuroendoscopic technique - endoscopic ventriculocisternostomy of the floor of the third ventricle. A surgical instrument with a camera at the end is inserted into the ventricles of the brain. The image from the camera is transmitted to the monitor, which allows you to accurately control all manipulations. At the bottom of the third ventricle an additional hole is created that connects to the cisterns of the base of the brain. This restores the physiological outflow of cerebrospinal fluid between the ventricles and cisterns.

If you or your loved ones have signs of hydrocephalus, call the Yusupov Hospital, where the call center is open 24 hours a day. Neurologists will conduct an examination and, after establishing a diagnosis, will draw up an individual treatment plan. The staff of the neurology clinic is attentive to the wishes of patients.

Why does dropsy of the brain occur?

In adult patients, acquired hydrocephalus is often encountered, which develops either due to any mechanical damage to the head, or as a result of the development of pathological processes. Why does cerebrospinal fluid accumulate outside the cerebral hemispheres? The explanation is simple: brain structures are disrupted, adhesions appear in the veins, arachnoid villi are destroyed, and as a result, the cerebrospinal fluid does not circulate as it should.

If we delve deeper into the question of the causes of such a disease as external dropsy of the brain, we can identify some factors:

infectious diseases (tuberculosis, meningitis, encephalitis);
post-stroke condition, development of sepsis, extensive hemorrhage;
concussion, head or cervical spine injury;
malignant tumors that develop in the stem region.

Frequent intoxication of the body leads to the appearance of external hydrocephalus. For example, alcohol abuse, which damages neurons and leads to tissue death. Those patients who suffer from metabolic disorders, diabetes mellitus, multiple sclerosis, encephalopathy, and atherosclerosis are also at risk. Another reason that deserves due attention is irreversible age-related changes that cause aging of blood vessels and brain tissue.

Main services of Dr. Zavalishin’s clinic:

consultation with a neurosurgeon
treatment of spinal hernia
brain surgery
spine surgery

How long do people live with this diagnosis?

When cerebral hydrocephalus is diagnosed in an adult, life expectancy depends on several factors:

age of the patient;
duration of disease development;
intensity of symptoms;
selected treatment methods;
reasons for the development of hydrocephalus of the brain.

Most patients manage to return to a full life after treatment, as timely assistance was provided. Some patients decide to visit a doctor when the symptoms of the disease become intense and difficult to bear, in which case the chances of recovery decrease.