Symptoms of Hydrocephalus
The primary symptoms of hydrocephalus include headache, nausea/vomiting, visual disturbances, gait abnormalities, cognitive changes, and increased head circumference in infants, with presentation varying based on age of onset and rate of progression. 1, 2
Age-Specific Presentation
Infants and Young Children
- Progressive increase in head circumference (macrocephaly) - most distinctive sign in infants 3
- Bulging fontanel and splayed sutures
- Prominent scalp veins
- "Setting sun" eye sign (downward gaze with visible sclera above iris)
- Irritability and lethargy
- Poor feeding
- Vomiting
- High-pitched cry
- Developmental delays
Older Children and Adolescents
- Headache (typically worse in the morning or with position changes)
- Nausea and vomiting
- Visual disturbances (diplopia, blurred vision)
- Papilledema
- Balance and coordination problems
- Declining school performance
- Behavioral changes
- Lethargy
Adults
- Persistent headache
- Nausea/vomiting
- Visual changes including diplopia
- Gait disturbances (70% of cases) 4
- Cognitive impairment (70% of cases) 4
- Urinary urgency (48% of cases) 4
- Impaired job performance (84% of cases) 4
- Memory problems
- Personality changes
Cardinal Signs of Increased Intracranial Pressure
- Headache - typically worse in the morning or with position changes
- Nausea and vomiting - often projectile, especially in the morning
- Visual disturbances - including diplopia, blurred vision, and Parinaud's syndrome (inability to look upward) 1
- Altered mental status - ranging from mild lethargy to profound obtundation
Specific Symptom Patterns
Normal Pressure Hydrocephalus (NPH) Triad
- Gait disturbance (magnetic gait) - typically first symptom
- Cognitive impairment
- Urinary incontinence or urgency
Shunt Malfunction Symptoms
- Recurrence of original hydrocephalus symptoms
- Can present with either high or low intracranial pressure symptoms 5, 6
- Low-pressure symptoms often worsen when upright and improve when lying down 6
Clinical Pearls
Symptom progression often correlates with the rate of ventricular enlargement rather than absolute size 1
Subtle presentation in young and middle-aged adults often leads to delayed diagnosis (average 6 years from symptom onset to diagnosis) 4
Discrepancy between symptoms and signs is common in young and middle-aged adults - symptoms may be prominent while clinical signs remain subtle 4
Positional symptoms (worse when upright, better when lying down) may indicate low-pressure hydrocephalus in shunted patients 6
Sagittal suture splaying is perhaps the most reliable indication of increased pressure in infants 1
Diagnostic Considerations
- Symptoms may mimic other neurological conditions, requiring imaging confirmation
- Cranial ultrasonography is the preferred initial imaging for infants 1
- MRI provides the most detailed assessment of ventricular size and etiology 1
- CT can provide critical information in emergency settings, including presence of hydrocephalus and mass effect 1
Remember that hydrocephalus symptoms vary widely based on age, etiology, and whether the condition is acute or chronic. Early recognition and treatment are essential to prevent permanent neurological damage and optimize outcomes.