What are the symptoms of hydrocephalus?

Symptoms of Hydrocephalus

Hydrocephalus typically presents with headache, altered mental status, gait disturbances, nausea/vomiting, and visual changes, with specific symptom patterns varying by age and etiology. 1

Common Symptoms Across All Age Groups

• Headache - Often worse when upright or with activity, may be relieved by lying down 1
• Nausea and vomiting - Particularly in acute presentations 1
• Altered mental status - Ranging from mild confusion to lethargy and obtundation 1
• Visual disturbances - Including diplopia, blurred vision, and visual field defects 1
• Gait abnormalities - Ranging from subtle changes to frank instability 1, 2

Age-Specific Presentations

Infants

• Increasing head circumference (macrocephaly) - Most common presentation in infants 1, 3
• Bulging fontanel - Often tense and non-pulsatile 1
• Splaying of cranial sutures - Progressive widening, especially of the sagittal suture 1
• Sunset eyes - Downward deviation of eyes with visible sclera above iris 1
• Irritability and lethargy - Often fluctuating 1

Children

• Headache - Often worse in the morning or with position changes 1, 3
• School performance decline - Cognitive changes may be subtle initially 2
• Balance problems - May present as clumsiness or frequent falls 2, 3
• Personality changes - Including irritability and decreased interest in activities 4, 2

Adults

• Cognitive impairment - Memory problems, difficulty concentrating, slowed thinking 2
• Gait disturbances - Often subtle, without frank apraxia in younger adults 2
• Urinary urgency - Occurs in approximately 48% of young and middle-aged adults 2
• Occupational difficulties - 84% of young and middle-aged adults report impaired job performance 2

Symptoms by Type of Hydrocephalus

Acute Obstructive Hydrocephalus

• Rapid onset of symptoms - Hours to days 1
• Severe headache - Often described as the worst headache of life 1
• Altered consciousness - Ranging from confusion to coma 1
• Papilledema - Due to increased intracranial pressure 1
• Cranial nerve palsies - Particularly affecting eye movements (Parinaud's syndrome) 1

Normal Pressure Hydrocephalus

• Gait disturbance - Magnetic, broad-based, shuffling gait 2
• Cognitive decline - Often misdiagnosed as dementia 2
• Urinary incontinence - Late symptom in disease progression 2

Low-Pressure Hydrocephalus

• Positional symptoms - Worse when upright, improved when lying down 5, 6
• Intermittent headache - Often related to position changes 5, 6
• Diplopia - With paresis of upward gaze 6
• Minimal strabismus - May be subtle on examination 6

Warning Signs Requiring Urgent Evaluation

• Sudden severe headache - May indicate acute hydrocephalus or hemorrhage 1
• Rapid deterioration in mental status - From lethargy to obtundation 1
• New onset seizures - Particularly in previously stable patients 1
• Bradycardia with hypertension - Cushing's triad, indicating critical elevation of intracranial pressure 1
• Respiratory irregularities - Including apnea in infants 1

Clinical Pitfalls

• Symptoms may be subtle - Especially in young and middle-aged adults, with discrepancy between prominent symptoms and subtle clinical signs 2
• Diagnostic delay - Average 6 years from symptom onset to diagnosis in young and middle-aged adults 2
• Normal pressure readings - Some patients may have normal or even low intracranial pressure despite symptomatic hydrocephalus 5, 6
• Overlap with other conditions - Symptoms may mimic primary headache disorders, dementia, or other neurological conditions 1, 2

Early recognition of hydrocephalus symptoms is crucial as timely intervention can significantly improve outcomes and prevent permanent neurological damage 4, 2.