September 11, 2025 • 23 mins
Hydrocephalus: What is it? What causes it? What are the symptoms? In this episode, we will discuss the history, how we currently treat hydrocephalus and how it is diagnosed. Tune in to learn more!
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Resources:
Hydrocephalus Association (US): https://www.hydroassoc.org/
The Brain Charity (UK): https://www.thebraincharity.org.uk/
Hydrocephalus Support Association (AUS): https://hydrocephalus.org.au/
References:
https://pubmed.ncbi.nlm.nih.gov/10547004/
https://www.pregnancybirthbaby.org.au/about-the-fontanelle
https://www.mayoclinic.org/diseases-conditions/hydrocephalus/symptoms-causes/syc-20373604
https://my.clevelandclinic.org/health/diseases/17334-hydrocephalus
https://www.mayoclinic.org/diseases-conditions/hydrocephalus/diagnosis-treatment/drc-20373609
https://pmc.ncbi.nlm.nih.gov/articles/PMC10132478/
https://www.britannica.com/biography/Akhenaten
https://www.hydroassoc.org/danny-bonaduces-mystery-illness-explained/
https://pmc.ncbi.nlm.nih.gov/articles/PMC3029661/
https://www.thebraincharity.org.uk/condition/hydrocephalus/
https://www.colgate.com/en-us/oral-health/root-canals/gutta-percha-what-is-it-and-when-is-it-used
https://www.forbes.com/sites/quora/2018/09/26/what-is-catgut-really-made-from/
https://my.clevelandclinic.org/health/diseases/15849-normal-pressure-hydrocephalus-nph
*This podcast is for entertainment purposes only. If you suspect you have a medical condition, please seek out an opinion of a medical professional.*
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
As you put your four-month-old daughter, Grace, to bed, you swear her head looks larger than
(00:05):
usual.
You feel like it has been growing rapidly over the past few days.
You told this to one of your mum friends, but she assured you that it's just the lack
of sleep.
You are just seeing things.
After all, Grace has been more irritable and fussy than usual.
She has also been eating less and seems to be vomiting more often.
You put this down to some bug going around, but as you move the tiny strands of hair on
(00:27):
her little head, you notice that she has a bulge on top of her head, which you know is
definitely not normal.
To reassure yourself, you decide to take Grace to the emergency room.
(00:53):
Hello and Welcome to Anatomy Of Illness.
Today's episode is about hydrocephalus.
Before we get into the condition, we are going to start with the history.
So why do we know hydrocephalus exists?
Before we get into the history, I have a quick announcement.
We have just launched our Kickstarter for the next season.
The link will be in the description, so be sure to check that out.
Now onto the history of hydrocephalus.
(01:15):
It is unclear when the first ever case of hydrocephalus was to have occurred, as it
seems to have been rather common in the past.
However, there have been skeletons of hydrocephalus found that have been dated all the way back
to around 2500 BC.
Now if we jump forward to between 1353 and 1336 BC and over to the 18th dynasty in ancient
(01:39):
Egypt, this is where we find something interesting.
This is still prior to the actual texts about hydrocephalus.
However, we see the pharaoh Akhenaten, who is also known as the heretic pharaoh or Amenhotep
the fourth.
In depictions of him, he has an abnormally shaped head.
Now there is a lot of controversy surrounding that of Akhenaten on whether or not his head
(02:02):
could be deemed abnormal, as well as for quite some time there was much speculation on whose
mummy was his mummy, because the mummy that is now speculated to be him was in such bad
form and also in an unusual position.
It was also thought to be a woman, it's not, it's a man actually.
This could be due to the view of him being a heretic, so that's why he was left and his
(02:24):
tomb was never actually finished.
And his line also ending with his son Tutankhamun, yes, I'm talking about King Tut, or Akhenaten's
mummification may have been done badly, which is why he may have been very poorly preserved.
Either way, there is now DNA evidence proving the mummy that was speculated to be him is
him based on measurements of Akhenaten's head, their head is abnormally large, however, it
(02:49):
is still considered to be within the normal range.
So it is actually unlikely that they did have hydrocephalus making the enlarged head in
artwork also more likely to be an artistic choice to do with the creation of his cult,
cult of Aton or cult of the sun's disc.
Now jumping forward to Hippocrates between 466 to 377 BC, he would describe various symptoms
(03:13):
that he would associate with the liquefaction of the brain due to seizures.
Yes, you heard me right, liquefaction of the brain, so the brain going to liquid.
These symptoms included headaches, vomiting, diplopia, which is double vision and visual
disturbances.
The term hydrocephalus would also come from the works of Hippocrates stemming from two
Greek words, the first being 'hydor' meaning water and the second being 'kefale' meaning
(03:38):
head, so water head or water on the brain.
However, this was not a term used to describe the medical condition in Hippocrates' text.
Instead, it was actually used to describe fluid collection surrounding the brain.
This being conditions like subdural hydromatter, dilation of the intracranial subarachnoid
space and arachnoid cysts that are adjacent to the calvaria, which is the top part of
(04:01):
your skull.
This is all of the things he called hydrocephalus rather than what we call hydrocephalus.
Now we move forward to Galen between 130 to 200 AD.
Galen, who would only dissect animals as this is all that was allowed at the time, would
actually have a good knowledge of the brain anatomy, even providing us with the first
(04:21):
description of cerebrospinal fluid, describing it as a clear watery liquid.
However, he would also attribute it to transporting pneuma, which was believed to be a life force
of some sorts.
Galen would also be the first to create classifications of fluid collections in the head.
“There are four kinds of hydrocephalus between the brain and the meninges, between the meninges
(04:42):
and the bone, between the bone and the pericranium and between the bone and the skin.
We treat hydrocephalus between the skin and the pericranium with two or three free incisions.
That between the meninges is incurable.”
So like Hippocrates, he would only see hydrocephalus as fluid accumulation outside of the ventricles.
This is likely due to only being able to dissect animals and not actually study cases of disease
(05:05):
through autopsy.
Now we are going to jump forward between 936 to 1013 with Albucasis.
He would describe what he believed to be the cause of infantile hydrocephalus, his belief
being that it was caused by mechanical compression.
The skull of a newborn is often full of liquid, either because the matron has compressed it
excessively or for other unknown reasons.
(05:26):
The volume of the skull then increases daily so that the bones of the skull fail to close.
In this case, we must open the middle of the skull in three places, make the liquid flow
out, then close the wound and tighten the skull with a bandage.”
Now it would be quite some time before we would have any other progress or results,
this in part being due to the middle ages as well as long standing ban on the use of
(05:48):
cadavers.
But that would be until the Renaissance.
This is when the dissection of human cadavers would become tolerated.
So this is when we would see the first ever drawing of the ventricular system within the
human brain in 1510.
But by who?
Well, Leonardo da Vinci, of course.
Now moving forward to 1555 with Andreas Vesalius, this is with the first description of hydrocephalus
(06:12):
stemming from an autopsy.
“I observed in Augsburg in a two year old girl whose head had grown in seven months more
or less to a size that was not surpassed in bulk by any man's head I ever saw.
This disease was what the ancients called hydrocephalus from water which is stored in
the head and gradually collects.
In this girl's case, however, the water had not collected between the skull and its outer
(06:34):
surrounding membrane or the skin where doctors books teach the water is deposited in other
cases but in the right and left ventricles of the cavity of the brain itself.
The breadth of these cavities had so increased and the brain itself was so distended that
they contained about nine pounds of water or three Augsburg wine measures.
So help me God, just as the brain itself at the vertex was membrane-like in thinness,
(06:58):
indistinguishable from its own membranous covering, so was the skull membranous.”
Vesalius would only find water in the ventricles of the brain and this would correct the idea
for the past 2000 years that the issue causing hydrocephalus was fluid in the other areas
of the brain.
Vesalius had met and examined the girl before she passed away.
With this, he would be surprised that she actually did have full use of her senses even
(07:21):
with what he found on her autopsy.
Moving on to 1744.
With Le Cat, this would be the first documented case of ventricular puncture.
In the case of this surgery, Le Cat would leave a wick in the surgical site to allow
for the excess fluid to escape.
In most documented cases of ventricular puncture surgery, they would end in death except for
the case in 1769.
(07:42):
This being by Fantoni who reported that their surgery ended in a permanent cure.
However, this being a surgery literally putting a hole in your head, don't go doing it, there
is no guarantee for success, especially with this time using no antiseptic, nothing to
clean the sites and no way to keep it clean and no one washing their hands of course.
The first modern case of this surgery would be performed in 1881 by Wernicke using aseptic
(08:06):
conditions meaning clean and free from contaminations.
He would write on this, "When performed in aseptic precautions, this operation is
intrinsically perfectly safe.” and many more seem to be taking this on but in 1902 we would
see some criticisms of the procedure.
Oppenheim criticizing Henschen's review of 63 cases when a patient's had this procedure.
(08:27):
Oppenheim found that of these 63, 24 had died in the aftermath of the surgery, 12 had absolutely
no benefit from the treatment and only a select few from the 63 actually had some improvement.
During this time, there was actually only the occasional benefit reported from ventricular
puncture.
But there were also extreme downsides linked with the surgery.
(08:49):
These downsides being side effects and these being most often in the form of infections.
Around this time, we would also have the development of extraventricular drainage techniques.
Wernicke would on occasion leave cannulas in as a way to allow the excess fluid to drain
off.
He yet again encouraged others to do the same.
We would see a variety of methods and materials used in this including hollow needles, rubber
(09:12):
tubes, gutta percha which is a plant material that makes latex.
It is also used in root canals to fill the tooth.
Wicks made out of various materials including catgut which is a suture material.
It is made from the intestines of sheep and cattle.
The name most likely comes from the old term to do with a medieval instrument similar to
a violin but a lot smaller.
(09:32):
This instrument is known as a kytte.
Anyway, other wicks were made out of silk or horse hair.
Oppenheim also did not like this and also criticized it again in 1902.
“VP and subsequent drainage of the ventricles as first recommended by Wernicke and applied
by von Bergmann, Keen, Kocher, Broca, Robsen and Watson-Cheyne has proven to be particularly
(09:55):
dangerous as 20 of the 23 individuals so treated died.
External drainage from the skull occasionally taken to such an extreme that the scalp drenched
in the spirit of turpentine is actually set on fire has actually found advocates again
lately but can hardly be considered seriously anymore.”
Even with the criticism, Fedor Krause in 1911 would successfully drain hydrocephalic ventricles
(10:19):
for 8 weeks to the outside of the body.
This without any form of infection occurring.
Moving on to 1949 with Frank Nulsen and Eugen Spitz, this is when the first clinically successful
shunt would be invented.
In 1956, we would see the work of John D. Holter.
He was a technician in Philadelphia whose son had severe hydrocephalus.
(10:40):
Holter is who we partially have to thank for valves and neurosurgery.
This being in his fight to save his son, it would only take a few weeks, but he would
manage to design his own valve.
This valve being first implanted in the March of 1956.
Now we jump into the year 1960 with the children's author Roald Dahl.
However we aren't going to be discussing his books.
(11:01):
We are going to be discussing an incident that happened with his son Theo who was four
months old at the time and the aftermath.
In 1960, the Dahl family were living in New York.
It would be here that Theo would be sadly hit by a New York taxi.
He would survive the accident, however he would end up developing secondary hydrocephalus
from all of his injuries.
(11:21):
Because of this, a ventricular atrial shunt would be inserted to help with his condition.
Now in January of 1961, the Dahl family would move back to the United Kingdom.
But Theo would have continuous issues with his shunt's Holter valve getting clogged.
So a children's author, a toy maker and a pediatric neurosurgeon would walk into an
operating room.
Yes, I am serious.
(11:42):
These three being Roald Dahl, Stanley Wade, who was a toy maker specialising in hydraulic
pumps for model aeroplanes and Kenneth Till, the pediatric neurosurgeon.
Would invite the other two to his operating room to see how shunts work to figure out how to
build a better device, including a different introducer as this was part of the problem.
This is where we get the Wade-Dahl-Till valve.
(12:04):
These were cheaper to manufacture, were able to be sanitised and had less issues with obstruction
than the previous.
Theo, interestingly enough, would never actually receive one of these valves as his hydrocephalus
was no longer an issue when they were being inserted into people.
If you're enjoying this episode, be sure to share it with a friend as it helps us grow.
So what actually is hydrocephalus?
(12:25):
Hydrocephalus is what we call the build up of fluid within the ventricles of the brain.
These are the cavities deep within the brain.
When there is excess fluid in these cavities, there is increased pressure inside of the
brain.
This also increases the size of the ventricles.
This fluid is also known as cerebral spinal fluid or CSF, which is necessary for brain
health.
However, too much and it causes damage to the brain because you can actually have too
(12:48):
much of a good thing.
But what can cause hydrocephalus?
Well, there are several things that can cause hydrocephalus, but the cause will depend on
the person.
What can cause the CSF to build up leading to hydrocephalus include an obstruction.
This is the most common cause of hydrocephalus.
This is a partial blockage to the flow of cerebral spinal fluid.
This blockage can be in the passage between one ventricle to another or in the passages
(13:12):
from the ventricles to the other spaces in the brain.
Overproduction.
This is the least common cause of hydrocephalus.
In this case, the CSF is produced at a rate faster than it can be absorbed.
Poor absorption.
So this is less common than an obstruction, but more common than overproduction.
This cause is often related to inflammation within the brain.
So this inflammation can be caused by either a disease or an injury.
(13:35):
What are the risk factors that increase the risk of developing hydrocephalus?
The risk factors vary by age.
So there are risk factors that are very specific to newborns and risk factors that can present
at any age.
When it comes to hydrocephalus in newborns, if it was present before birth or at the time
of birth, then this is known as congenital hydrocephalus.
However, when it comes to infants, it can also develop shortly after birth.
(13:56):
So for newborns, these risk factors include the central nervous system developing incorrectly.
This being in a way that causes the flow of CSF to be blocked, having bleeding within
the ventricles.
This is occasionally seen as a complication that can occur with premature birth and infection
during gestation.
So if the mother was to develop an infection like rubella or syphilis during pregnancy,
(14:18):
this can cause inflammation in the brain tissues in the unborn baby.
This can cause hydrocephalus.
Risk factors that anyone of any age can experience when it comes to hydrocephalus include having
a tumor of the brain or the spinal cord, experiencing an infection in the central nervous system.
These being infections like mumps or bacterial meningitis, experiencing bleeding in the brain
either from a stroke or another head injury, experiencing a traumatic injury to the brain.
(14:43):
So how does a doctor diagnose hydrocephalus?
When it comes to a diagnosis of hydrocephalus, doctors will discuss symptoms, do a general
physical exam, as well as a neurological exam before requesting brain imaging tests.
When it comes to imaging tests, there are several options that can be done.
These include ultrasounds.
When it comes to hydrocephalus in infants, a doctor may actually start imaging tests
(15:04):
by using an ultrasound.
With this, a technician can use an ultrasound probe on the fontanel, this being soft spot
on the top of the baby's head.
Interestingly enough, during prenatal ultrasounds, so during pregnancy ultrasounds, hydrocephalus
may also be found in cases of congenital hydrocephalus.
MRI.
This is another testing option that may be used when it comes to MRI, it is painless.
(15:26):
However, it can be rather noisy, so mild sedation may have to be used as you have to be incredibly
still for this test.
And babies aren't always as good at staying still.
CT scans.
This is another option when it comes to testing, which again, may require some mild sedations
as again, with this test, you have to be very still for it.
We will get right into the symptoms and presentation right after this little break.
(16:01):
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While symptoms might you have if you were to have hydrocephalus.
With hydrocephalus, the symptoms can vary with age.
We see this condition most often in infants and adults above the age of 60.
So for this condition, we should break it down by age group starting with infants.
The symptoms you may see in infants include changes to the head.
This can include things like a head that is larger than usual, a rapid increase in the
(16:25):
size of your infant's head or a bulge in the soft spot or a tense soft spot on the
top of the head.
Again, these soft spots are known as fontanelles.
Don't go poking at it hard as the brain is not protected by the skull in that area at
this time.
But a very, very, very gentle touch is okay.
If you are thinking that this is bulging, this is a sign to seek medical advice immediately
(16:47):
because it's not supposed to do that.
Infants can also show other signs that are not just changes to their head size and shape.
These include nausea and vomiting, poor eating, lethargy.
So this is sleepiness or sluggishness, irritability, issues with their muscle tone and strength,
seizures, sunsetting of the eyes.
This is when the eyes are fixed downward.
(17:08):
So they won't look upward or anything like that.
They don't have the ability to look upward.
Moving on from infants, now onto toddlers and older children.
They can also experience hydrocephalus.
Their symptoms may also include changes in their behaviour and cognitive abilities.
So they may have a sudden change in their personality.
They may become irritable, experience delays or changes in their school performance or
(17:28):
their abilities.
So they may also experience delays or problems with skills they had.
So this can include things like crawling, talking and walking.
Along with these symptoms, they may also experience for toddlers, their head may become
enlarged because if they are still young enough, their head can still expand because the soft
spot hasn't hardened.
It hasn't become the full on hard skull that we have as adults.
(17:50):
In general, children may experience headaches, blurred vision or double vision.
They may have eye movements that may be abnormal.
They may experience sleepiness or sluggishness.
They may have trouble with their balance or coordination, nausea and vomiting, poor appetite,
loss of control of their bladder or they may urinate more frequently.
Moving on to young and middle aged adults.
(18:10):
So in young and middle aged adults, the most common symptoms include headaches, vision
problems, experiencing a decline in your memory, your ability to concentrate or any other skills
that may affect your performance at work, loss of coordination or balance.
You may also feel sluggish or sleepy.
You may also experience a loss in your ability to control your bladder or feel the urge to
urinate more often than you used to.
(18:32):
When it comes to older adults, so adults above the age of 60, they also have their own set
of symptoms.
These include poor coordination and balance, trouble with walking.
With this symptom, the person may feel as if their feet are stuck or they may shuffle
when they walk.
They may also have their feet turned out slightly.
So if you've ever seen a penguin walk, they may walk a little bit like a penguin, a bit
odd, but that is kind of like a telltale sign.
(18:55):
Memory loss, experiencing a progressive loss of thinking and reasoning skills.
They may also experience a loss of bladder control or an urge to urinate more often.
So in older adults, their symptoms mimic dementia, Alzheimer's, essentially those kinds of conditions.
However, this is more treatable.
Their symptoms are also known as Hakim's triad.
So 50 to 75% of older adults will have those three symptoms, which is cognitive decline
(19:20):
type symptoms, urination issues and coordination.
So walking issues, which is the penguin type walk, the shuffling, the feeling like your
feet are kind of stuck on the floor, which is a good way to tell the difference between
Parkinson's Alzheimer's dementia versus, you know, hydrocephalus, which is normal pressure
hydrocephalus in adults, especially older adults, because when you measure the pressure,
(19:45):
it's still technically within normal range, however, higher end of the spectrum.
What complications should a doctor be aware of when it comes to hydrocephalus?
When it comes to hydrocephalus, a doctor should be aware of several complications.
These include learning disabilities, developmental disabilities, and physical disabilities.
When hydrocephalus is left untreated in infants, it can put increased pressure on the brain
(20:06):
as it gets more severe, so as more and more fluid builds up.
In some cases, this condition can even lead to death.
Doctors should also be aware of normal pressure hydrocephalus.
This is a buildup of cerebrospinal fluid that occurs more often in older people than it
does in younger people.
So think 60, 65 plus.
This puts pressure on the brain and mimics the symptoms of dementia, but normal pressure
(20:26):
hydrocephalus is much more treatable.
How do we treat hydrocephalus?
When it comes to hydrocephalus, this condition is primarily treated through surgery.
The surgeries that can be done to treat hydrocephalus include shunts.
This is the most common treatment for hydrocephalus.
A shunt is a long flexible tube that has a valve.
This keeps the fluid flowing correctly, so in the right direction and right pace, preventing
(20:47):
there from being too much fluid in the ventricles.
With the shunt, one end goes into the brain's ventricles and the other leads into another
part of the body like the stomach or the heart.
This is done so the fluid can easily be absorbed elsewhere.
There is also another surgery, but this is a less common surgery.
It is known as an endoscopic third ventriculostomy.
With this surgery, a surgeon uses a small camera to see inside of the brain.
(21:10):
Once in the right place, a surgeon will make a small hole in the bottom of the ventricle
to allow for the fluid to flow out of the brain.
Are there any famous people who have or have had hydrocephalus?
Yes, there are a few famous people who have had hydrocephalus, including Danny Bonaduce.
You may remember as Danny Partridge from the Partridge family.
Danny Bonaduce was diagnosed with normal pressure hydrocephalus back in 2023.
(21:33):
This condition mimics Alzheimer's disease, which we discussed in episode 46.
However, normal pressure hydrocephalus, unlike Alzheimer's, is much more treatable.
Because of this, Bonaduce required a shunt in his brain to help drain off excess fluid.
If you would like to check out a foundation for those in the US, there is the Hydrocephalus
Association.
They aim to find a cure for hydrocephalus and improve the lives of those experiencing
(21:55):
the condition.
They do this by funding research into hydrocephalus and providing support for those who are experiencing
the condition along with their families.
For those in the UK, there is the Brain Charity.
They provide support to those experiencing a condition affecting the brain such as hydrocephalus
along with supporting their family as well.
And for those in Australia, there is the Hydrocephalus Support Association.
Their aim is to support those who are living with hydrocephalus.
(22:18):
If you want to check out the sources, social media links or any other links, you can head
to anatomyofillness.com.
If you enjoyed this episode and would like to hear more, subscribe to be notified about
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If you would like to join our community, you can join us on Discord or Instagram.
Otherwise stick around for the next episode.
(22:46):
Did you know that the cerebrospinal fluid actually has several functions?
These include cushioning the brain from injury, allowing the brain to float in your skull
as without it, your brain is pretty heavy and would potentially crush itself.
It is also important for waste removal when it comes to the brain's metabolism.
As you put your four-month-old daughter, Grace, to bed, you swear her head looks larger than
(00:05):
usual.
You feel like it has been growing rapidly over the past few days.
You told this to one of your mum friends, but she assured you that it's just the lack
of sleep.
You are just seeing things.
After all, Grace has been more irritable and fussy than usual.
She has also been eating less and seems to be vomiting more often.
You put this down to some bug going around, but as you move the tiny strands of hair on
(00:27):
her little head, you notice that she has a bulge on top of her head, which you know is
definitely not normal.
To reassure yourself, you decide to take Grace to the emergency room.
(00:53):
Hello and Welcome to Anatomy Of Illness.
Today's episode is about hydrocephalus.
Before we get into the condition, we are going to start with the history.
So why do we know hydrocephalus exists?
Before we get into the history, I have a quick announcement.
We have just launched our Kickstarter for the next season.
The link will be in the description, so be sure to check that out.
Now onto the history of hydrocephalus.
(01:15):
It is unclear when the first ever case of hydrocephalus was to have occurred, as it
seems to have been rather common in the past.
However, there have been skeletons of hydrocephalus found that have been dated all the way back
to around 2500 BC.
Now if we jump forward to between 1353 and 1336 BC and over to the 18th dynasty in ancient
(01:39):
Egypt, this is where we find something interesting.
This is still prior to the actual texts about hydrocephalus.
However, we see the pharaoh Akhenaten, who is also known as the heretic pharaoh or Amenhotep
the fourth.
In depictions of him, he has an abnormally shaped head.
Now there is a lot of controversy surrounding that of Akhenaten on whether or not his head
(02:02):
could be deemed abnormal, as well as for quite some time there was much speculation on whose
mummy was his mummy, because the mummy that is now speculated to be him was in such bad
form and also in an unusual position.
It was also thought to be a woman, it's not, it's a man actually.
This could be due to the view of him being a heretic, so that's why he was left and his
(02:24):
tomb was never actually finished.
And his line also ending with his son Tutankhamun, yes, I'm talking about King Tut, or Akhenaten's
mummification may have been done badly, which is why he may have been very poorly preserved.
Either way, there is now DNA evidence proving the mummy that was speculated to be him is
him based on measurements of Akhenaten's head, their head is abnormally large, however, it
(02:49):
is still considered to be within the normal range.
So it is actually unlikely that they did have hydrocephalus making the enlarged head in
artwork also more likely to be an artistic choice to do with the creation of his cult,
cult of Aton or cult of the sun's disc.
Now jumping forward to Hippocrates between 466 to 377 BC, he would describe various symptoms
(03:13):
that he would associate with the liquefaction of the brain due to seizures.
Yes, you heard me right, liquefaction of the brain, so the brain going to liquid.
These symptoms included headaches, vomiting, diplopia, which is double vision and visual
disturbances.
The term hydrocephalus would also come from the works of Hippocrates stemming from two
Greek words, the first being 'hydor' meaning water and the second being 'kefale' meaning
(03:38):
head, so water head or water on the brain.
However, this was not a term used to describe the medical condition in Hippocrates' text.
Instead, it was actually used to describe fluid collection surrounding the brain.
This being conditions like subdural hydromatter, dilation of the intracranial subarachnoid
space and arachnoid cysts that are adjacent to the calvaria, which is the top part of
(04:01):
your skull.
This is all of the things he called hydrocephalus rather than what we call hydrocephalus.
Now we move forward to Galen between 130 to 200 AD.
Galen, who would only dissect animals as this is all that was allowed at the time, would
actually have a good knowledge of the brain anatomy, even providing us with the first
(04:21):
description of cerebrospinal fluid, describing it as a clear watery liquid.
However, he would also attribute it to transporting pneuma, which was believed to be a life force
of some sorts.
Galen would also be the first to create classifications of fluid collections in the head.
“There are four kinds of hydrocephalus between the brain and the meninges, between the meninges
(04:42):
and the bone, between the bone and the pericranium and between the bone and the skin.
We treat hydrocephalus between the skin and the pericranium with two or three free incisions.
That between the meninges is incurable.”
So like Hippocrates, he would only see hydrocephalus as fluid accumulation outside of the ventricles.
This is likely due to only being able to dissect animals and not actually study cases of disease
(05:05):
through autopsy.
Now we are going to jump forward between 936 to 1013 with Albucasis.
He would describe what he believed to be the cause of infantile hydrocephalus, his belief
being that it was caused by mechanical compression.
The skull of a newborn is often full of liquid, either because the matron has compressed it
excessively or for other unknown reasons.
(05:26):
The volume of the skull then increases daily so that the bones of the skull fail to close.
In this case, we must open the middle of the skull in three places, make the liquid flow
out, then close the wound and tighten the skull with a bandage.”
Now it would be quite some time before we would have any other progress or results,
this in part being due to the middle ages as well as long standing ban on the use of
(05:48):
cadavers.
But that would be until the Renaissance.
This is when the dissection of human cadavers would become tolerated.
So this is when we would see the first ever drawing of the ventricular system within the
human brain in 1510.
But by who?
Well, Leonardo da Vinci, of course.
Now moving forward to 1555 with Andreas Vesalius, this is with the first description of hydrocephalus
(06:12):
stemming from an autopsy.
“I observed in Augsburg in a two year old girl whose head had grown in seven months more
or less to a size that was not surpassed in bulk by any man's head I ever saw.
This disease was what the ancients called hydrocephalus from water which is stored in
the head and gradually collects.
In this girl's case, however, the water had not collected between the skull and its outer
(06:34):
surrounding membrane or the skin where doctors books teach the water is deposited in other
cases but in the right and left ventricles of the cavity of the brain itself.
The breadth of these cavities had so increased and the brain itself was so distended that
they contained about nine pounds of water or three Augsburg wine measures.
So help me God, just as the brain itself at the vertex was membrane-like in thinness,
(06:58):
indistinguishable from its own membranous covering, so was the skull membranous.”
Vesalius would only find water in the ventricles of the brain and this would correct the idea
for the past 2000 years that the issue causing hydrocephalus was fluid in the other areas
of the brain.
Vesalius had met and examined the girl before she passed away.
With this, he would be surprised that she actually did have full use of her senses even
(07:21):
with what he found on her autopsy.
Moving on to 1744.
With Le Cat, this would be the first documented case of ventricular puncture.
In the case of this surgery, Le Cat would leave a wick in the surgical site to allow
for the excess fluid to escape.
In most documented cases of ventricular puncture surgery, they would end in death except for
the case in 1769.
(07:42):
This being by Fantoni who reported that their surgery ended in a permanent cure.
However, this being a surgery literally putting a hole in your head, don't go doing it, there
is no guarantee for success, especially with this time using no antiseptic, nothing to
clean the sites and no way to keep it clean and no one washing their hands of course.
The first modern case of this surgery would be performed in 1881 by Wernicke using aseptic
(08:06):
conditions meaning clean and free from contaminations.
He would write on this, "When performed in aseptic precautions, this operation is
intrinsically perfectly safe.” and many more seem to be taking this on but in 1902 we would
see some criticisms of the procedure.
Oppenheim criticizing Henschen's review of 63 cases when a patient's had this procedure.
(08:27):
Oppenheim found that of these 63, 24 had died in the aftermath of the surgery, 12 had absolutely
no benefit from the treatment and only a select few from the 63 actually had some improvement.
During this time, there was actually only the occasional benefit reported from ventricular
puncture.
But there were also extreme downsides linked with the surgery.
(08:49):
These downsides being side effects and these being most often in the form of infections.
Around this time, we would also have the development of extraventricular drainage techniques.
Wernicke would on occasion leave cannulas in as a way to allow the excess fluid to drain
off.
He yet again encouraged others to do the same.
We would see a variety of methods and materials used in this including hollow needles, rubber
(09:12):
tubes, gutta percha which is a plant material that makes latex.
It is also used in root canals to fill the tooth.
Wicks made out of various materials including catgut which is a suture material.
It is made from the intestines of sheep and cattle.
The name most likely comes from the old term to do with a medieval instrument similar to
a violin but a lot smaller.
(09:32):
This instrument is known as a kytte.
Anyway, other wicks were made out of silk or horse hair.
Oppenheim also did not like this and also criticized it again in 1902.
“VP and subsequent drainage of the ventricles as first recommended by Wernicke and applied
by von Bergmann, Keen, Kocher, Broca, Robsen and Watson-Cheyne has proven to be particularly
(09:55):
dangerous as 20 of the 23 individuals so treated died.
External drainage from the skull occasionally taken to such an extreme that the scalp drenched
in the spirit of turpentine is actually set on fire has actually found advocates again
lately but can hardly be considered seriously anymore.”
Even with the criticism, Fedor Krause in 1911 would successfully drain hydrocephalic ventricles
(10:19):
for 8 weeks to the outside of the body.
This without any form of infection occurring.
Moving on to 1949 with Frank Nulsen and Eugen Spitz, this is when the first clinically successful
shunt would be invented.
In 1956, we would see the work of John D. Holter.
He was a technician in Philadelphia whose son had severe hydrocephalus.
(10:40):
Holter is who we partially have to thank for valves and neurosurgery.
This being in his fight to save his son, it would only take a few weeks, but he would
manage to design his own valve.
This valve being first implanted in the March of 1956.
Now we jump into the year 1960 with the children's author Roald Dahl.
However we aren't going to be discussing his books.
(11:01):
We are going to be discussing an incident that happened with his son Theo who was four
months old at the time and the aftermath.
In 1960, the Dahl family were living in New York.
It would be here that Theo would be sadly hit by a New York taxi.
He would survive the accident, however he would end up developing secondary hydrocephalus
from all of his injuries.
(11:21):
Because of this, a ventricular atrial shunt would be inserted to help with his condition.
Now in January of 1961, the Dahl family would move back to the United Kingdom.
But Theo would have continuous issues with his shunt's Holter valve getting clogged.
So a children's author, a toy maker and a pediatric neurosurgeon would walk into an
operating room.
Yes, I am serious.
(11:42):
These three being Roald Dahl, Stanley Wade, who was a toy maker specialising in hydraulic
pumps for model aeroplanes and Kenneth Till, the pediatric neurosurgeon.
Would invite the other two to his operating room to see how shunts work to figure out how to
build a better device, including a different introducer as this was part of the problem.
This is where we get the Wade-Dahl-Till valve.
(12:04):
These were cheaper to manufacture, were able to be sanitised and had less issues with obstruction
than the previous.
Theo, interestingly enough, would never actually receive one of these valves as his hydrocephalus
was no longer an issue when they were being inserted into people.
If you're enjoying this episode, be sure to share it with a friend as it helps us grow.
So what actually is hydrocephalus?
(12:25):
Hydrocephalus is what we call the build up of fluid within the ventricles of the brain.
These are the cavities deep within the brain.
When there is excess fluid in these cavities, there is increased pressure inside of the
brain.
This also increases the size of the ventricles.
This fluid is also known as cerebral spinal fluid or CSF, which is necessary for brain
health.
However, too much and it causes damage to the brain because you can actually have too
(12:48):
much of a good thing.
But what can cause hydrocephalus?
Well, there are several things that can cause hydrocephalus, but the cause will depend on
the person.
What can cause the CSF to build up leading to hydrocephalus include an obstruction.
This is the most common cause of hydrocephalus.
This is a partial blockage to the flow of cerebral spinal fluid.
This blockage can be in the passage between one ventricle to another or in the passages
(13:12):
from the ventricles to the other spaces in the brain.
Overproduction.
This is the least common cause of hydrocephalus.
In this case, the CSF is produced at a rate faster than it can be absorbed.
Poor absorption.
So this is less common than an obstruction, but more common than overproduction.
This cause is often related to inflammation within the brain.
So this inflammation can be caused by either a disease or an injury.
(13:35):
What are the risk factors that increase the risk of developing hydrocephalus?
The risk factors vary by age.
So there are risk factors that are very specific to newborns and risk factors that can present
at any age.
When it comes to hydrocephalus in newborns, if it was present before birth or at the time
of birth, then this is known as congenital hydrocephalus.
However, when it comes to infants, it can also develop shortly after birth.
(13:56):
So for newborns, these risk factors include the central nervous system developing incorrectly.
This being in a way that causes the flow of CSF to be blocked, having bleeding within
the ventricles.
This is occasionally seen as a complication that can occur with premature birth and infection
during gestation.
So if the mother was to develop an infection like rubella or syphilis during pregnancy,
(14:18):
this can cause inflammation in the brain tissues in the unborn baby.
This can cause hydrocephalus.
Risk factors that anyone of any age can experience when it comes to hydrocephalus include having
a tumor of the brain or the spinal cord, experiencing an infection in the central nervous system.
These being infections like mumps or bacterial meningitis, experiencing bleeding in the brain
either from a stroke or another head injury, experiencing a traumatic injury to the brain.
(14:43):
So how does a doctor diagnose hydrocephalus?
When it comes to a diagnosis of hydrocephalus, doctors will discuss symptoms, do a general
physical exam, as well as a neurological exam before requesting brain imaging tests.
When it comes to imaging tests, there are several options that can be done.
These include ultrasounds.
When it comes to hydrocephalus in infants, a doctor may actually start imaging tests
(15:04):
by using an ultrasound.
With this, a technician can use an ultrasound probe on the fontanel, this being soft spot
on the top of the baby's head.
Interestingly enough, during prenatal ultrasounds, so during pregnancy ultrasounds, hydrocephalus
may also be found in cases of congenital hydrocephalus.
MRI.
This is another testing option that may be used when it comes to MRI, it is painless.
(15:26):
However, it can be rather noisy, so mild sedation may have to be used as you have to be incredibly
still for this test.
And babies aren't always as good at staying still.
CT scans.
This is another option when it comes to testing, which again, may require some mild sedations
as again, with this test, you have to be very still for it.
We will get right into the symptoms and presentation right after this little break.
(16:01):
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While symptoms might you have if you were to have hydrocephalus.
With hydrocephalus, the symptoms can vary with age.
We see this condition most often in infants and adults above the age of 60.
So for this condition, we should break it down by age group starting with infants.
The symptoms you may see in infants include changes to the head.
This can include things like a head that is larger than usual, a rapid increase in the
(16:25):
size of your infant's head or a bulge in the soft spot or a tense soft spot on the
top of the head.
Again, these soft spots are known as fontanelles.
Don't go poking at it hard as the brain is not protected by the skull in that area at
this time.
But a very, very, very gentle touch is okay.
If you are thinking that this is bulging, this is a sign to seek medical advice immediately
(16:47):
because it's not supposed to do that.
Infants can also show other signs that are not just changes to their head size and shape.
These include nausea and vomiting, poor eating, lethargy.
So this is sleepiness or sluggishness, irritability, issues with their muscle tone and strength,
seizures, sunsetting of the eyes.
This is when the eyes are fixed downward.
(17:08):
So they won't look upward or anything like that.
They don't have the ability to look upward.
Moving on from infants, now onto toddlers and older children.
They can also experience hydrocephalus.
Their symptoms may also include changes in their behaviour and cognitive abilities.
So they may have a sudden change in their personality.
They may become irritable, experience delays or changes in their school performance or
(17:28):
their abilities.
So they may also experience delays or problems with skills they had.
So this can include things like crawling, talking and walking.
Along with these symptoms, they may also experience for toddlers, their head may become
enlarged because if they are still young enough, their head can still expand because the soft
spot hasn't hardened.
It hasn't become the full on hard skull that we have as adults.
(17:50):
In general, children may experience headaches, blurred vision or double vision.
They may have eye movements that may be abnormal.
They may experience sleepiness or sluggishness.
They may have trouble with their balance or coordination, nausea and vomiting, poor appetite,
loss of control of their bladder or they may urinate more frequently.
Moving on to young and middle aged adults.
(18:10):
So in young and middle aged adults, the most common symptoms include headaches, vision
problems, experiencing a decline in your memory, your ability to concentrate or any other skills
that may affect your performance at work, loss of coordination or balance.
You may also feel sluggish or sleepy.
You may also experience a loss in your ability to control your bladder or feel the urge to
urinate more often than you used to.
(18:32):
When it comes to older adults, so adults above the age of 60, they also have their own set
of symptoms.
These include poor coordination and balance, trouble with walking.
With this symptom, the person may feel as if their feet are stuck or they may shuffle
when they walk.
They may also have their feet turned out slightly.
So if you've ever seen a penguin walk, they may walk a little bit like a penguin, a bit
odd, but that is kind of like a telltale sign.
(18:55):
Memory loss, experiencing a progressive loss of thinking and reasoning skills.
They may also experience a loss of bladder control or an urge to urinate more often.
So in older adults, their symptoms mimic dementia, Alzheimer's, essentially those kinds of conditions.
However, this is more treatable.
Their symptoms are also known as Hakim's triad.
So 50 to 75% of older adults will have those three symptoms, which is cognitive decline
(19:20):
type symptoms, urination issues and coordination.
So walking issues, which is the penguin type walk, the shuffling, the feeling like your
feet are kind of stuck on the floor, which is a good way to tell the difference between
Parkinson's Alzheimer's dementia versus, you know, hydrocephalus, which is normal pressure
hydrocephalus in adults, especially older adults, because when you measure the pressure,
(19:45):
it's still technically within normal range, however, higher end of the spectrum.
What complications should a doctor be aware of when it comes to hydrocephalus?
When it comes to hydrocephalus, a doctor should be aware of several complications.
These include learning disabilities, developmental disabilities, and physical disabilities.
When hydrocephalus is left untreated in infants, it can put increased pressure on the brain
(20:06):
as it gets more severe, so as more and more fluid builds up.
In some cases, this condition can even lead to death.
Doctors should also be aware of normal pressure hydrocephalus.
This is a buildup of cerebrospinal fluid that occurs more often in older people than it
does in younger people.
So think 60, 65 plus.
This puts pressure on the brain and mimics the symptoms of dementia, but normal pressure
(20:26):
hydrocephalus is much more treatable.
How do we treat hydrocephalus?
When it comes to hydrocephalus, this condition is primarily treated through surgery.
The surgeries that can be done to treat hydrocephalus include shunts.
This is the most common treatment for hydrocephalus.
A shunt is a long flexible tube that has a valve.
This keeps the fluid flowing correctly, so in the right direction and right pace, preventing
(20:47):
there from being too much fluid in the ventricles.
With the shunt, one end goes into the brain's ventricles and the other leads into another
part of the body like the stomach or the heart.
This is done so the fluid can easily be absorbed elsewhere.
There is also another surgery, but this is a less common surgery.
It is known as an endoscopic third ventriculostomy.
With this surgery, a surgeon uses a small camera to see inside of the brain.
(21:10):
Once in the right place, a surgeon will make a small hole in the bottom of the ventricle
to allow for the fluid to flow out of the brain.
Are there any famous people who have or have had hydrocephalus?
Yes, there are a few famous people who have had hydrocephalus, including Danny Bonaduce.
You may remember as Danny Partridge from the Partridge family.
Danny Bonaduce was diagnosed with normal pressure hydrocephalus back in 2023.
(21:33):
This condition mimics Alzheimer's disease, which we discussed in episode 46.
However, normal pressure hydrocephalus, unlike Alzheimer's, is much more treatable.
Because of this, Bonaduce required a shunt in his brain to help drain off excess fluid.
If you would like to check out a foundation for those in the US, there is the Hydrocephalus
Association.
They aim to find a cure for hydrocephalus and improve the lives of those experiencing
(21:55):
the condition.
They do this by funding research into hydrocephalus and providing support for those who are experiencing
the condition along with their families.
For those in the UK, there is the Brain Charity.
They provide support to those experiencing a condition affecting the brain such as hydrocephalus
along with supporting their family as well.
And for those in Australia, there is the Hydrocephalus Support Association.
Their aim is to support those who are living with hydrocephalus.
(22:18):
If you want to check out the sources, social media links or any other links, you can head
to anatomyofillness.com.
If you enjoyed this episode and would like to hear more, subscribe to be notified about
our latest episodes.
If you would like to join our community, you can join us on Discord or Instagram.
Otherwise stick around for the next episode.
(22:46):
Did you know that the cerebrospinal fluid actually has several functions?
These include cushioning the brain from injury, allowing the brain to float in your skull
as without it, your brain is pretty heavy and would potentially crush itself.
It is also important for waste removal when it comes to the brain's metabolism.
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