University of Central Florida NGR 5141/ NGR - Module 12

1. Differentiate between the clinical findings commonly associated with congenital hydrocephalus that occurs in infancy and those commonly associated with hydrocephalus that occurs in older children. Congenital hydrocephalus is manifested by an increased volume for CSF. This can be caused by a blockage within the ventricular system in which the CSF flows, an imbalance in production of the CSF, or a reduced reabsorption of the CSF that results in ventricular enlargement and increased ICP. Congenital hydrocephalus may cause fetal death in utero, or the increased head circumference may require cesarean delivery of the infant. Symptoms generally depend directly on the cause and rate of hydrocephalus development. Infants may be asymptomatic at birth. However, within the first few weeks of life, the head begins to grow at an abnormal rate. Significant dilation of the ventricles may occur before an abnormal increase in head growth develops. The fontanels enlarge and bulge. Macewen sign occurs and causes a resonant note from the separation of the cranial sutures when the skull is tapped. The infant may have difficulty holding up its head, the scalp skin is thin and shiny and scalp veins may become prominent. The infant also has a high pitched cry as ICP rises. The infant may show other signs such as irritability, lethargy, and vomiting. In older children with hydrocephalus, the head may not have the capacity to enlarge and evidence of increased ICP is present. Older children generally have a type of hydrocephalus called noncommunicating hydrocephalus. This may result from congenital abnormalities in the ventricular system or mass lesions such as a tumor that compresses one of the structures of the ventricular system. They may present with signs such as declining memory and cognitive function and an unsteady or broad based gait with history of falling is common. Additionally, they may have signs and symptoms of apathy, inattentiveness, and indifference to self, family, and environment. 2. Two individuals come to the emergency room with head injuries. One, 25 years of age, has just been in a motor vehicle accident (MVA) and has a temporal lobe injury. The other, 65 years of age, has increasing confusion following a fall that happened earlier in the week. How could you clinically differentiate between the individual with the extradural hematoma and the individual with the subdural hematoma? Which one of these individuals requires priority surgical treatment? An extradural hematoma is most commonly found in those who have experienced motor vehicle accidents and generally occurs in those aged 20 to 40. An artery is the source of bleeding in 85% of extradural hematomas due to injury to the meningeal vein or dural sinus. In classic temporal extradural hematomas, individuals usually experience a loss of consciousness at the time of injury followed by a lucid period that lasts from a few hours to a few days (in one third of individuals, if bleeding from a vein). As the hematoma forms, the patient can experience a headache of increasing severity, vomiting, drowsiness, confusion, seizure, and hemiparesis. Level of consciousness may decline as the temporal lobe herniation begins. They may also have ipsilateral pupillary dilation and contralateral hemiparesis. This type of hematoma is almost always an emergency and can be treated through surgery by evacuation of the hematoma through burr holes followed by ligation of the bleeding vessel(s). A subdural hematoma is commonly associated with falls in older adults. This type of hem