Hydrocephalus in Adults

While hydrocephalus is typically a disease that strikes children, there are several forms that can affect adults.

The most common forms of hydrocephalus to be seen in adults are obstructive hydrocephalus, normal pressure hydrocephalus, and pseudotumor cerebri (idiopathic intracranial hypertension).  The evaluation and treatment of these is often quite different.

In adult onset of obstructive hydrocephalus, there is usually a mechanical blockage of the spinal fluid flow including tumors, webbings, Chiari malformation or prior hemorrhage.  The usual treatment involves either endoscopic third ventriculostomy or shunting.  If an MRI or CAT scan shows hydrocephalus and the patient is asymptomatic, immediate evaluation is appropriate.

The condition of normal pressure hydrocephalus (NPH) is different than many forms of hydrocephalus.  This disease typically is seen in older patients.  The three classic symptoms are gait difficulties, memory difficulties, and difficulty controlling one’s bladder.  These symptoms can also be seen in many forms of dementia, so careful evaluation is needed in order to decide whether a particular patient would benefit from shunting, which is the only treatment for NPH.  At UNC we use a team that includes neurologists, neurosurgeons, physical therapists and speech therapists to perform a lumbar drain trial in patients being considered for shunting.  The patients are admitted to the hospital and have testing of their gait and cognitive function, a lumbar spinal drain is then placed and several days of spinal drainage is performed.  If patients have significant improvement, as judged by their physical therapy and cognitive testing by their family’s evaluation, and by the physician’s evaluations, a ventriculoperitoneal shunt is often placed.  If the patients do not benefit from the lumbar drain, then it is presumed that the permanent shunting procedure would not benefit and other ideologies are sought for the patient’s clinical difficulties.

Pseudotumor cerebri is a third and distinct form of adult hydrocephalus that involves high brain pressures without dilatation of the brain spaces.  It is frequently seen in younger women with primary symptoms being headaches and visual difficulties.  In severe cases, swelling in the back of the eyes, termed papilledema, can be seen by a skilled ophthalmologist and identify high brain pressure.  Initial treatment is usually medicine to reduce spinal fluid production, but if this is unsuccessful, shunting procedures can be necessary to protect the patient’s vision.  At UNC we have traditionally performed an image-guided, stereotactically placed ventriculoperitoneal shunt for treatment of this condition primarily in patients for whom vision loss or impending vision loss is the primary issue.

Attention to adult hydrocephalus is frequently not a high priority for many neurosurgeons, but at UNC we have a strong interest in hydrocephalus in both adults and children and are happy to see patients who are suffering from it.

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