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HYDROCEPHALUS

03 July 2012 - dalam NURSING Oleh carentule-fkp11

CHAPTER I

INTRODUCTION

 

1.1  Background

Hydrocephalus is an abnormal expansion of cavities (ventricles) within the brain that is caused by the accumulation of cerebrospinal fluid. The pressure of hydrocephalus is very dangerous.  It results in decreased blood flow, which in turn decreases functioning in that area of the brain. The longer the duration of increased pressure, the greater likelihood that this loss of function will be permanent. Continued pressure on the optic nerve is also dangerous, it can permanently damage the nerve, and destroy vision. There are many specific symptom of hydrocephalus, such as Eyes that appear to gaze downward, Irritability, Seizures, Separated sutures, and Sleepiness.

The prevalence of infant hydrocephalus in Sweden by 1982 is 0.63/1000 births, while in US by 1988 as 0.9/1000 births. The prevalence of hydrocephalus in Indonesia have been not reported.

Until now, the therapy for hydrocephalus is only surgery. Even though surgery may bring any risk if something wrong was happen, this procedure must applied to the hydrocephalus patient. The earlier hydrocephalus can be detected or diagnosed, earlier shunt surgery can be performed, quicker patient grow and develop back to normal.

1.2  Objective

  1. What are the classification anatomy and physiology of Neurologic System?
  2. What are the Pathophysiology?
  3. What are types and classification of Hydrocephalus?
  4. What are etiologies of Hydrocephalus?
  5. What are the clinical appearances of Hydrocephalus?
  6. What are the diagnostic assessment for Hydrocephalus?
  7. What are therapy for Hydrocephalus patient?

1.3  Aim

  • To explain the concept of Hydrocephalus.

 

 

CHAPTER II

LITERATURE REVIEWS

 

2.1  Anatomy Physiology

Structure and function of the nervous system consists of nerve cells called neurons and supporting tissue called neuroglia which serves to form the central nervous system (CNS) and peripheral nervous system (SST). CNS consists of the brain and spinal cord while the peripheral nervous system is the nervous system outside the CNS that brings messages to and from the central nervous system. Stimulation received by both internal and external bodies will be able to adapt your body to stay balanced. Efforts of the body can adapt to changes that occur through neural activity known as reflex activity. When the body is unable to adapt, there will be an unbalanced condition or illness

Received by the receptor stimulation of the nervous system will then be delivered by the peripheral nervous system in the form of electrical impulses to the central nervous system. Part of the peripheral nervous system that receives stimuli are called receptors, and forwarded to the central nervous system by the sensory nervous system. In the central nervous system impulses then processed and interpreted for an answer or response forwarded back through the peripheral nervous system to trigger effector function as the final answer. Nervous system that brings an answer or response is the motor nerve system. Part of the peripheral nervous system that triggers the response is the effector. The answer happens to be the answer that will be affected by the (voluntary) and the answers are not influenced by the will (involuntary). The answer involves the voluntary somatic nervous system is involuntary while involving the autonomic nervous system. Effector of the somatic nervous skeletal muscle system while to the autonomic nervous system, the effector is smooth muscle, cardiac muscle and sebaceous glands.

 

 2.1.1             Nerve function is:

  • ·         Receive information (stimuli) from within and from outside the body through a sensory nerve. Afferent sensory nerves called the Sensory Pathway. 
  • ·         Communicating information between the peripheral nervous system and central nervous system. 
  • ·         Process the information received at both the spinal cord and the brain to further determine the answer or response. 
  • ·         Deliver answers quickly through the motor nerves to the organs of the body as a control or modification of the action. Motor nerves called motor Efferent Pathway. 

2.1.2         Brain

Brain, consisting of a large brain called the cerebrum, the cerebellum called the cerebellum and brain stem called the brainstem. Some typical characteristics of the adult brain has a weight that is more or less 2% of body weight and blood circulation gets 20% of cardiac output and requires calories by 400 kcal per day. The brain is the most widely used network was powered by energy from the oxidation of glucose metabolism.

The brain needs oxygen and glucose is relatively constant, this was caused by the metabolism of the brain that performs the process continuously without a significant break. When oxygen and glucose levels are less in the metabolism of brain tissue to be disrupted and the nerve tissue will be damaged. Structurally, the cerebrum is divided into sections called cerebral cortex and sub cortex called subcortical structures. Cerebral cortex consists of the sensory cortex that serves to recognize, interpret impulses received sensory so that individuals feel, knowing the sensation of taste/certain senses. Cortex of sensory also save a lot of data memory as a result of sensory stimulation for human life. Motor cortex serves to give an answer to stimuli it receives.

2.1.3         Sub-cortical structures

a)      Basal ganglia; perform detailing motor function and coordination with the basic movements, fine movements or skilled movements and gestures.

b)      Thalamus; is central to pain stimuli.

c)      The hypothalamus; highest center of integration and coordination of the autonomic nervous system and is involved in the processing of instinctual behaviors such as eating, drinking, sex and motivation.

d)     Pituitary

Together with the hypothalamus regulate the activities of most of the endocrine glands in the synthesis and release of hormones.

2.1.4         Cerebrum

Consists of two parts called Cerebral hemisphere and both are separated by a fissure longitudinalis.. Right hemisper and left are connected by a building called the corpus callosum. Hemisper cerebri is divided into lobes which are named according to the bone above it, namely:

  • ·         Frontal lobe, the cerebrum which is under the frontal bone.
  • ·         Parietal lobe, the cerebrum which is under the parietal bone.
  • ·         Occipitalis lobe, the cerebrum which is under the bone occipitalis.
  • ·         Temporal lobe, the cerebrum which is under the temporal bone.

2.1.5         Cerebellum (small brain)

Located in the back of cerebral posterior cranial fossa occupies the bottom layer Cerebelli durameter tentorium. On the front there is a brain stem. Cerebellum weight about 150 grams, or 8-8% of the total weight of the brain stem. Cerebellum can be divided into right and left hemisper cerebelli is separated by the vermis. Cerebellar function in general is coordinating the muscle movements that can be done with perfect motion.

2.1.6         The spinal cord

The spinal cord is an extension of the medulla oblongata to the caudal vertebral canal at the start as high as I cervical vertebral horn extending to the lumbar vertebral height horn I - II. Consists of 31 segments, every segments consisting of one pair of spinal nerves. That is 8 pairs of cervical spinal cord of 12 pairs thorakal, 5 pairs of lumbar part of the sacred and 5 pairs and 1 pair coxigeus exit the spinal cord. Meninges of spinal cord encased by a membrane that serves to protect the spinal cord from impact or injury. 

Spinal cord cross-sectional picture shows parts of the substantia grissea and white matter. Substantia grisea centralis so that it surrounds the canal forms the dorsal Columna, Columna Columna lateral and ventral. Grisea mass surrounded by white matter or white body-containing nerve fibers are enveloped by myelin. Alba substances containing nerve bundles that bring sensory impulses from the SST to the CNS and motor impulses from the CNS to the SST. Substantia grisea serves as a coordination center based in the spinal reflex spinalis. Substantia alba contain bundles of nerve impulses carrying sensory function of the edge of the peripheral nervous system to the brain and motor impulses from the brain to the peripheral nerves.

Sensory impulses from the left side of the body will be sent to the right side of the brain and otherwise. Similar to the mechanism of the motor impulse. The entire motor impulses from the brain that is delivered to the peripheral nerves through the spinal cord will cross.

Upper Motor Neuron (UMN) is a motor neuron derived from the motor cortex of the brain or brain stem entirely (with the nerve fibers in the central nervous system. Lower motor neuron (LMN) is the motor neurons derived from the system Central nervous but nerve fibers out of the central nervous system and form the peripheral nervous system and ending in skeletal muscle. UMN and LMN dysfunction causes paralysis of skeletal muscles, but the nature of the different nature of the paralysis UMN. LMN Damage caused paralysis of the muscles weak, muscle tension (tonus) of low and difficult to stimulate skeletal muscle reflex (hiporefleksia). In UMN damage, muscle paralysis (paralysis) and stiff (rigid), high muscle tension (hipertonus) and easily induced skeletal muscle reflex. File UMN medial section, branch of brains cross each other. While the Internal UMN still running on the same side to this lateral beam arrives at the spinal cord. With Thus the entire skeletal muscle motor impulse will cross, so that the UMN damage above the brain stem will lead to paralysis of the muscles on the opposite side.

One function of the spinal cord as a central nervous system is a reflex center. Function was organized by the spinal cord substantia grisea. Reflex is the individual response to stimuli, protecting the body against various changes in the environment both internal and external environment. Reflex activity occurs through a particular pathway called the reflex arc.

Spinal cord function is:

ü  The eye muscle is the largest body of ventral cornua.

ü  Care of spinal reflex activity and reflex limb

ü  Deliver stimulation to the muscle and joint coordination cerebellum

ü  Up communication between the brain with all parts of the body.

2.1.7         Bank of the Nervous System

Collection of neurons outside the brain and spinal cord form the peripheral nervous system (SST). In anatomic classified into the nerves of the brain as much as 12 pairs and 31 pairs of spinal nerves. Functionally, SST classified into: a) nerve sensory (afferent) Somatic: bringing information from the skin, skeletal muscles and joints, into the central nervous system, b) motor nerves (efferent) Somatic: bringing information from the central nervous system to skeletal muscle , c) sensory nerve (efferent) visceral: bringing information from the walls of the viscera to the central nervous system, d) motor nerve (efferent) visceral: bringing information from the central nervous system to smooth muscle, cardiac muscle and glands. Visceral efferent nerves called the autonomic nervous system. Peripheral nervous system consists of brain neurons (s. cranial) and spinal nerves.

 

2.1.8         Brain nerve (s. cranial)

When spinal nerves carry impulses from the peripheral information to the spinal cord and carry motor impulses from the spinal cord to the peripheral, then to 12 pairs of cranial nerves connect the pathway, the pathway to the brainstem. Cranial nerve that is in part a mixed nerve has sensory nerves and motor nerves

 

 

 

2.2  Definition of Hydrocephalus

The term hydrocephalus is derived from the Greek words "hydro" meaning water and "cephalus" meaning head. As the name implies, it is a condition in which the primary characteristic is excessive accumulation of fluid in the brain. Although hydrocephalus was once known as "water in the brain", the "water" is actually cerebrospinal fluid (CSF), a clear fluid that surrounds the brain and spinal cord. The excessive accumulation of CSF results in an abnormal widening of spaces in the brain called ventricles. This widening creates potentially harmful pressure on the tissues of the brain.

Hydrocephalus is a pathological disorder of the brain that lead to the increase in cerebrospinal fluid with or ever with an elevated intracranial pressure, so there is a widening of the ventricles. Ventricular dilation is due to an imbalance between production and absorption of cerebrospinal fluid. Hydrocephalus is always secondary, as a result of disease or brain damage. This disorder causes enlarged head and widening sutures.

Hydrocephalus is a disturbance of CSF physiology. The secretion of CSF by the choroid plexus is a metabolically active process involving ion pumps and enzyme systems similar to those found in the distal tubule of the kidney. CSF is indistinguishable from brain extracellular fluid, and because water and electrolytes pas freely in and out of the brain across the ependymal surface of the ventricular system, the brain itself is believed to be responsible for a small fraction of total CSF production. CSF secretion continues at a constant rate of about 20 million per day in adult humans. Age, body mass, and various disease states undoubtedly affect the rate of CSF secretion, but methodologies for studying these affects in human are problematic. Unlike CSF secretion, CSF reabsorption is a purely passive process driven in a linear fashion by the pressure differential between the subarachnoid space and the venous circulation, specifically, the major Dural venous sinuses within the cranial cavity. Thus the intra dural compartment does not stray far from a steady state characterized by equal CSF secretion and reabsorption and ICP within the normal range. With the rare exception of choroid plexus papilloma, a tumor of the choroid plexus that causes excessive CSF secretion, the diseases that cause hydrocephalus do so by interfering with CSF reabsorption. A higher pressure gradient is required to drive CSF back into the venous circulation, so, although all but the most acutely unstable patients with hydrocephalus eventually achieve a steady state between CSF secretion and reabsorption, they do so only at an abnormally high ICP.

Out of respect for historical tradition, hydrocephalus sometimes been characterized further as either communicating or obstructive O hydrocephalus. These terms date to the era of pneumoencephalography. If air introduced into the lumbar theca appeared eventually within the ventricles of the brain, the ventricles and the lumbar subarachnoid space were said to communicate. If air filled the dilated ventricles, such communicating hydrocephalus was presumed to be caused by obliteration of the subarachnoid spaces or the arachnoid granulations (the sites of CSF reabsorption in the dural venous sinuses) by diffuse inflammatory disease processes, such as meningitis or subarachnoid hemorrhage. Cases of hydrocephalus in which the ventricles could not filled with air introduced from below were attributed to lesions obstructing bulk flow of CSF. This dichotomy has limited usefulness today. Determining the category to which a patient belongs to the basis of history, physical examination, and even noninvasive imaging studies can be difficult, as contemporary experience with endoscopic third ventriculostomy (ETV) has shown.

 

2.3  Pathophysiology

Normal CSF production is 0.20-0.35 mL/min; most CSF is produced by the choroid plexus, which is located within the ventricular system, mainly the lateral and fourth ventricles. The capacity of the lateral and third ventricles in a healthy person is 20 ml. Total volume of CSF in an adult is 120 ml.

Normal route of CSF from production to clearance is the following from the choroid plexus, the CSF flows to the lateral ventricle, then to the interventricular foramen of Monro, the third ventricle, the cerebral aqueduct of Sylvius, the fourth ventricle, the 2 lateral foramina of Luschka and 1 medial foramen of Magendie, the subarachnoid space, the arachnoid granulations, the dural sinus, and finally into the venous drainage.

ICP rises if production of CSF exceeds absorption. This occurs if CSF is overproduced, resistance to CSF flow is increased, or venous sinus pressure is increased. CSF production falls as ICP rises. Compensation may occur through transventricular absorption of CSF and also by absorption along nerve root sleeves. Temporal and frontal horns dilate first, often asymmetrically. This may result in elevation of the corpus callosum, stretching or perforation of the septum pellucidum, thinning of the cerebral mantle, or enlargement of the third ventricle downward into the pituitary fossa (which may cause pituitary dysfunction).

The mechanism of NPH has not been elucidated completely. Current theories include increased resistance to flow of CSF within the ventricular system or subarachnoid villi; intermittently elevated CSF pressure, usually at night; and ventricular enlargement caused by an initial rise in CSF pressure the enlargement is maintained despite normal pressure because of the Laplace law. Although pressure is normal, the enlarged ventricular area reflects increased force on the ventricular wall.

Hydrocephalus appears most commonly in the newborn period as a reslt of an IVH originating from periventricular germinal matrix. In the premature infant in particular, the walls of blood vessels in the germinal matrix region lack substantial external tissue support. They supply blood to the rapidly dividing cells of the germinal matrix, which is the site of origin for both neuronal and glial cells ultimately destined for cortex. Hese fragile vessels are exposed to arterial and venous hemodynamic surges in the premature infant and can rupture, usually within the first 72 hours of life.

The severity of the hemorrhage is traditionally grade by Papile’s criteria. There are several modifications of this scale, but as reported by Whitelaw, grade 1 is germinal matrix hemorrhage without extension into the ventricle, grade 2 is IVH involving up to 50 % of ventricular area and not dilating the ventricle, and grade 3 is IVH involving grater than 50 % ventricular area and dilating the ventricle. Grade 4 is traditionally considered to have an intraparenchymal component outside the germinal matrix region, although Volpe argues that intraparenchymal hemorrhage should be reported separately from the grading of the IVH. In addition, Volpe’s interpretation of IVH grades does not specifically refer to ventricular dilatation as part of the criteria, limiting consideration to percentage of ventricular volume occupied by the clot.

Hydrocephalus is theoretically due to three mechanisms, namely:

  1. Excessive production liquor.
  2. Increased flow resistance liquor.
  3. Increased pressure sinus venosa.

Consequences of the above three mechanisms is an increase in intracranial pressure as an effort to maintain the balance of secretion and absorption. The mechanism of ventricular dilatation is quite complicated and different place each time during the development of hydrocephalus. Dilatation occurs as a result of:

  1. Compression cerebrovascular system.
  2. Redistribution of extracellular fluid or cerebrospinal liquor.
  3. Mechanical changes of the brain.
  4. Pulse pressure effect liquor cerebrospinal.
  5. The loss of brain tissue.
  6. Volume enlargement of the skull due to abnormal strain cranial suture.

Liquor caused by choroid plexus tumors that over-production. Liquor flow interruption is the beginning of most cases of hydrocephalus. Increased flow resistance caused disruption will increase proportionally liquor pressure in an effort to maintain a balanced reabsorpsi.

Venous sinus pressure elevation has two consequences, namely increased cortical venous pressure, causing increased intracranial vascular volume and increased intracranial pressure to the extent necessary to maintain the flow of liquor against venous sinus pressure is relatively high. A clinical consequence of venous hypertension depends on the compliance of the skull.

2.4  Types and Classification

a)      Obstructive. This form also called non-communicating hydrocephalus, occurs when a blockage in a ventricle restricts the flow of CSF.

b)      Non-obstructive. This form also called communicating hydrocephalus occurs when CSF is not absorbed properly into the bloodstream.

c)      Normal Pressure Hydrocephalus. Occurs often with age as the result of a gradual blockage and build-up of CSF.

d)     Congenital. Occurs during fetal development and is present at birth.

e)      Acquired. Occurs after birth usually as a result of trauma to the brain through infection or injury, meningitis or tumor.

2.5  Etiology

Hydrocephalus is due to a problem with the flow of cerebrospinal fluid (CSF), the liquid that surrounds the brain and spinal cord. The fluid brings nutrients to the brain, takes away waste from the brain, and acts as a cushion.

CSF normally moves through areas of the brain called ventricles, then around the outside of the brain and the spinal cord. It is then reabsorbed into the bloodstream. Build up of CSF can occur in the brain if it's flow or absorption is blocked, or if too much CSF is produced. This build up of fluid puts pressure on the brain, pushing the brain up against the skull and damaging or destroying brain tissues.

Hydrocephalus may start while the baby is growing in the womb. It is commonly present with Myelomeningocele , a birth defect involving incomplete closure of the spinal column. Genetic defects and certain infections that occur during pregnancy may also cause hydrocephalus.

In young children, hydrocephalus may also be associated with the following conditions:

  1. a.      Infections that affect the central nervous system (such as Meningitis or Encephalitis), especially in infants.
  2. b.      Bleeding in the brain during or soon after delivery (especially in premature babies).
  3. c.       Injury before, during, or after childbirth, including subarachnoid hemorrhage.
  4. d.      Tumors of the central nervous system, including the brain or spinal cord.
  5. e.       Injury or trauma.

Hydrocephalus most often occurs in children, but may also occur in adults and the elderly.

 

2.6  Clinical appearances

The symptoms depend on the cause of the blockage, the person's age, and how much brain tissue has been damaged by the swelling.

In infants with hydrocephalus, CSF fluid builds up in the central nervous system, causing Fontanele to bulge and the head to be larger than expected. Early symptoms may also include:

  • Eyes that appear to gaze downward.
  • Irritability.
  • Seizures.
  • Separated sutures.
  • Sleepiness.
  • Vomiting.
  • Enlargement of the head.

Symptoms that may occur in older children can include:

  • Brief, shrill, high-pitched cry.
  • Changes in personality, memory, or the ability to reason or think.
  • Changes in facial appearance and eye spacing.
  • Crossed eyes or uncontrolled eye movements.
  • Difficulty feeding.
  • Excessive sleepiness.
  • Headache.
  • Irritability, poor temper control.
  • Loss of bladder control (urinary incontinence).
  • Loss of coordination and trouble walking.
  • Muscle spasticity (spasm).
  • Slow growth (child 0-5 years).
  • Slow or restricted movement.
  • Vomiting.

 

2.7  Diagnostic Assessment

  1. Risk of damage to skin integrity related to damage the ability to move his head secondary to head size.
  2. Risk of injury associated with the inability to support a large head and a sense of tension in the neck.
  3. The risk of imbalance nutrition: less than body requirements related to secondary vomiting and irritability caused by cerebral compression.
  4. Ineffectiveness of risk management program therapeutic associated with less knowledge, home care, signs and symptoms of infection, increased intracranial pressure and the emergency treatment of shunt.

When a health care provider taps fingertips on the skull, there may be abnormal sounds that indicated thinning and separation of skull bones. Scalp veins may appear stretched or enlarged.

Part or the entire head may be larger than normal. Enlargement is most commonly seen in the front part of the head. Head circumference measurements, repeated over time, may show that the head is getting bigger.

The eyes may look "sunken in." The white part of the eye may appear above the colored part of the eye, given the eyes a "setting-sun" appearance. Reflexes may be abnormal.

A head CT scan is one of the best tests for identifying hydrocephalus. Other tests that may be done include:

  • Arteriography.
  • Brain scan using radioisotopes.
  • Cranial ultrasound (an ultrasound of the brain).
  • Lumbar puncture and examination of the cerebrospinal fluid (rarely done).
  • Skull x-rays.

 

2.8         The Therapy

Hydrocephalus treatment is surgical, generally creating various types of cerebral shunts. It involves the placement of a ventricular catheter (a tube made of silastic), into the cerebral ventricles to bypass the flow obstruction/malfunctioning arachnoidal granulations and drain the excess fluid into other body cavities, from where it can be resorbed. Most shunts drain the fluid into the peritoneal cavity (Ventriculo peritoneal shunt), but alternative sites include the right atrium (ventriculo-atrial shunt), pleural cavity (ventriculo-pleural shunt), and gallbladder. A shunt system can also be placed in the lumbar space of the spine and have the CSF redirected to the peritoneal cavity (Lumbar-peritoneal shunt). An alternative treatment for obstructive hydrocephalus in selected patients is the endoscopic third ventriculostomy (ETV), whereby a surgically created opening in the floor of the third ventricle allows the CSF to flow directly to the basal cisterns, thereby shortcutting any obstruction, as in aqueductal stenosis. This may or may not be appropriate based on individual anatomy.

People with hydrocephalus will have their shunt tubing replaced at least once due to growth. The shunt may also have to be replaced due to a number of complications. The most common of such complications are:

a)      Obstruction

The tubing may become plugged with blood elements, brain fragments or tumor cells. Scar tissue or structures may obstruct the ends of the tubing as well. Symptoms of an obstructed shunt are similar to those for hydrocephalus.

b)      Infection or Erosion

Infection should be suspected is there is unusual swelling along the shunt tract visible behind the ear.

c)      Overdrainage

Symptoms are similar to those of hydrocephalus with the most common being a severe headache which is reduced when lying down.

 

CHAPTER III

CONCLUTION

 

3.1  Conclution

Hydrocephalus is theoretically occur as a result of three mechanisms, namely Excessive production liquor, Increased flow resistance liquor, Increased pressure sinus venosa. Types and Classification of Hydrocephalus are Obstruktive; Non-obstruktive; Normal Pressure Hydrocephalus; Congenital; and Acquired. The Etiology of Hydrocephalus Congenital Abnormalities (Congenital), Infection, Neoplasm, and Bleeding. Clinical manifestations of hydrocephalus in children are grouped into two categories, namely hydrocephalus occurs in the neonatal period and hydrocephalus occurs in late childhood.

The diagnostic assessments are enlargement of the head can occur in hydrocephalus, makrosefali, brain tumor, brain abscess, intracranial granuloma, and perinatal subdural hematoma, hidranensefali. The Therapy for Hydrocephalus, basically there are three principles in the treatment of hydrocephalus, namely Reduce production of CSF, Affect the relationship between the production site with the absorption of CSF, Expenditure liquor (CSS) into the extracranial organs.

 

 

3.2  Suggestion

Follow-up examinations generally continue throughout the child's life. These are done to check the child's developmental level and to treat any intellectual, neurological, or physical problems.

Visiting nurses, social services, support groups, and local agencies can provide emotional support and assist with the care of a child with hydrocephalus who has significant brain damage.

 

BIBLIOGRAPHY

Nursalam. 2010. English in Nursing – Midwifery Science and Technology. Surabaya: Salemba Medika.

Ropper, Allan H. And Robert H. Brown. 2005. Adams And Victor’s Principles Of Neurology: Eight Edition. USA.

Darsono dan Himpunan Dokter Spesialis Saraf Indonesia dengan UGM. 2005. Buku Ajar Neurologi Klinis. Yogyakarta: UGM Press.

http://www.medicinenet.com/hydrocephalus/article.htm diakses pada pukul 16.00 WIB tanggal 09 Mei 2012.



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