Hydrocephalus: Comprehensive Guide to Diagnosis and Treatment

Hydrocephalus, commonly known as “water on the brain,” is a neurological condition that affects individuals in Singapore each year. This condition occurs when cerebrospinal fluid (CSF) accumulates abnormally within the brain’s ventricles. CSF is a clear fluid that cushions and protects the brain and spinal cord, and the ventricles are hollow spaces where this fluid is usually produced and circulated. When excess fluid builds up, pressure within the skull may increase, which can affect surrounding brain tissue.

Hydrocephalus can develop at any age, from infancy through adulthood. Neurosurgical care offers treatment options that may help manage the condition and support quality of life. Understanding this condition and recognising possible symptoms may help individuals seek timely medical assessment. Symptoms can vary and include headaches, vision problems, difficulty walking, or, in infants, an enlarged head.

Dr Teo Kejia (张哿佳医生)

Senior Consultant Neurosurgeon

MBBS (SG)MRCS (Edin)FAMS (Neuro Surg)FRCS Ed (Neuro Surg)IFAANS

Hydrocephalus: Comprehensive Guide to Diagnosis and Treatment

Overview Types Causes Symptoms When To See A Neurosurgeon Diagnosis Treatment Complications Prevention FAQS Conclusion

What is Hydrocephalus?

Hydrocephalus is a neurological condition characterised by an abnormal buildup of cerebrospinal fluid (CSF) within the brain’s ventricles. CSF normally circulates through the ventricles, surrounds the brain and spinal cord, and is absorbed into the bloodstream. When this balance between production and absorption is disrupted, excess fluid can accumulate, leading to enlargement of the ventricles and increased pressure on surrounding brain tissue.

Hydrocephalus can be congenital (present at birth) or acquired later in life due to factors such as injury, infection, or other medical conditions. Because increased pressure on the skull can affect brain function, a medical evaluation is important. With appropriate diagnosis and management by our neurosurgeon, some patients may experience symptom improvement and better day-to-day functioning, depending on individual circumstances.

Types of Hydrocephalus

Congenital Hydrocephalus

Present at birth, congenital hydrocephalus may result from developmental abnormalities during foetal development or genetic factors. This type may be detected during prenatal ultrasounds (imaging tests that use sound waves to create pictures of the baby before birth) or become apparent in the first few months of life. Babies with this condition may have an enlarged head circumference and may show developmental delays.
Acquired Hydrocephalus

Developing after birth, acquired hydrocephalus can affect individuals at any age. It may result from injury, disease, or other medical conditions that affect CSF production or absorption. This type can occur suddenly or develop gradually over time.
Normal Pressure Hydrocephalus (NPH)
Commonly affecting older adults, NPH is characterised by enlarged ventricles (fluid-filled spaces in the brain) but relatively normal CSF pressure readings. Patients may present with a triad of symptoms:
- Gait disturbance (difficulty walking)
- Cognitive decline (problems with thinking and memory)
- Urinary incontinence (loss of bladder control)
In some cases, NPH may be misdiagnosed as dementia or normal ageing.
Communicating vs Non-Communicating Hydrocephalus

Non-communicating (obstructive) hydrocephalus occurs when CSF flow is blocked within the ventricular system, meaning the fluid cannot move freely between the spaces in the brain. Whereas communicating hydrocephalus happens when CSF absorption is impaired despite normal flow through the ventricles. The fluid circulates normally but cannot be reabsorbed adequately into the bloodstream. This classification can help determine a suitable treatment approach.

Causes

Congenital malformations (birth defects of the brain and spine): Neural tube defects, aqueductal stenosis (narrowing of the channel that allows cerebrospinal fluid to flow between brain ventricles), and Dandy-Walker syndrome (a developmental condition involving abnormal formation of the cerebellum and surrounding fluid spaces)
Brain tumours: Growths that can block the pathways where cerebrospinal fluid flows
Infections: Meningitis (infection of the protective membranes around the brain and spinal cord), encephalitis (brain inflammation), or other central nervous system infections
Haemorrhage (bleeding): Bleeding into the fluid-filled spaces of the brain (intraventricular) or around the brain (subarachnoid)
Traumatic brain injury: Head injuries that can disrupt how cerebrospinal fluid circulates
Surgical complications: Following brain or spinal surgery

Risk Factors

Premature birth: May increase risk of bleeding into the brain’s fluid-filled spaces
Maternal infections during pregnancy: Rubella, cytomegalovirus, and toxoplasmosis
Genetic factors: A family history of neural tube defects (incomplete formation of the brain or spinal cord during early pregnancy)
Age: Infants and older adults may be at higher risk
Previous brain infections or injuries
Certain medical conditions: Spina bifida (a condition where the spine and spinal cord do not fully close during early development) and brain cysts (fluid-filled sacs in the brain)

Signs & Symptoms

Hydrocephalus symptoms vary significantly depending on age and progression rate. Early recognition can be important for timely medical evaluation.

Infants and Young Children

Rapid increase in head circumference
Bulging or tense fontanelle (the soft spot on a baby’s head)
Downward deviation of eyes (“sunsetting” sign)
Excessive sleepiness or irritability
Poor feeding and vomiting
Developmental delays
High-pitched crying

Older Children and Adults

Severe headaches, especially in the morning
Nausea and vomiting
Vision problems (such as blurred or double vision)
Balance and coordination difficulties
Cognitive changes or memory problems
Personality changes or irritability
Difficulty walking or gait changes

Elderly Patients (Normal Pressure Hydrocephalus)

Progressive gait disturbance (e.g., shuffling, magnetic gait)
Cognitive decline and confusion
Urinary urgency or incontinence
Difficulty with daily activities
Memory loss resembling dementia

Symptoms may progress over time if the condition is not addressed. Progression can be gradual in chronic cases or more rapid in acute hydrocephalus, which may require emergency medical attention.

Experiencing these symptoms?

Schedule a consultation with our Senior Consultant Neurosurgeon for a medical assessment and discussion of management options tailored to your individual needs.

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When to See a Neurosurgeon

Seeking timely medical attention can support appropriate management of hydrocephalus. Immediate medical attention is recommended if you or your child experiences sudden, severe headaches, projectile vomiting, seizures (sudden episodes of uncontrolled electrical activity in the brain causing symptoms like shaking or loss of consciousness), or changes in consciousness. These symptoms may indicate acute hydrocephalus requiring emergency treatment.

For infants, parents should consult a paediatrician if they notice rapid head growth, persistent irritability, or feeding difficulties. Developmental delays, such as missing milestones in sitting, crawling, or walking, also warrant evaluation.

Adults experiencing a gradual onset of cognitive changes (such as memory problems, confusion, or difficulty concentrating), walking difficulties, or urinary problems should consider scheduling a consultation, particularly if symptoms progressively worsen. During the first consultation, our neurosurgeon will perform a thorough neurological examination, review medical history, and may recommend imaging studies (such as CT scans or MRIs). Early medical assessment can help guide management and support timely intervention.

Diagnosis & Testing Methods

Accurate diagnosis of hydrocephalus requires a comprehensive evaluation combining clinical assessment with imaging techniques. The diagnostic process begins with a detailed medical history and a thorough neurological examination. During this examination, healthcare professionals evaluate reflexes, muscle strength, coordination, and cognitive function.

Magnetic Resonance Imaging (MRI)	Magnetic Resonance Imaging (MRI) provides detailed images of brain structures and cerebrospinal fluid (CSF) spaces. This imaging test uses magnetic fields and radio waves to create pictures of the brain without radiation. MRI can show ventricular enlargement (swelling of the fluid-filled spaces in the brain), identify obstructions (blockages in fluid flow), and help determine the type of hydrocephalus. Scan duration may vary depending on the specific protocol, and patients need to remain still during the procedure.
CT Scan	Computed Tomography (CT) Scan offers rapid imaging, making it valuable in emergency situations. This test uses X-rays to create cross-sectional pictures of the brain. While less detailed than MRI, CT scans can show ventricular size and detect bleeding or masses (abnormal growths). The procedure duration depends on the protocol and is often the first imaging study performed.
Lumbar Puncture	Lumbar Puncture measures CSF pressure and allows fluid analysis. Healthcare professionals use this procedure to check for infection or bleeding. It involves inserting a needle into the lower back to collect CSF for testing. In some cases, removing CSF may temporarily relieve symptoms and can provide information to guide treatment planning.
Intracranial Pressure Monitoring	Intracranial Pressure Monitoring involves placing a small sensor to continuously measure intracranial pressure. This test can help identify pressure patterns over time and may be useful for evaluating conditions such as normal pressure hydrocephalus (NPH), a form that typically affects older adults.
Neuropsychological Testing	Neuropsychological Testing evaluates cognitive function, memory, and processing speed. These assessments can help establish baseline function and monitor changes over time, which may support clinical decision-making, particularly for patients with NPH.

Treatment Options Overview

Treatment for hydrocephalus focuses on restoring normal CSF flow and reducing intracranial pressure (pressure inside the skull). Our neurosurgeon will assess each patient individually to determine suitable management options based on the type of hydrocephalus, age, and overall health status.

Surgical Shunt Systems

Ventriculoperitoneal (VP) shunt placement is a treatment option for hydrocephalus. During this procedure, the surgeon inserts a thin tube (catheter) into the brain ventricle, connected to a valve system that regulates fluid flow. Another catheter is tunnelled under the skin to drain excess CSF into the abdominal cavity, where the body naturally absorbs it. Programmable shunts allow non-invasive pressure adjustments using external magnetic devices, enabling adjustments without additional surgery. Some patients may experience symptom improvement, though response can vary depending on individual factors.

Endoscopic Third Ventriculostomy (ETV)

ETV provides an alternative approach for selected patients, particularly those with obstructive hydrocephalus (where CSF flow is blocked). Using endoscopic techniques (a thin tube with a camera and light), the neurosurgeon creates a small opening in the floor of the third ventricle. This allows CSF to bypass the obstruction and flow naturally. The procedure may reduce the need for permanent implants, and its benefits can vary depending on age and type of hydrocephalus. Our doctor can discuss whether this procedure might be suitable for your specific case.

Medical Management

Although surgery is often the definitive treatment, certain medications can provide temporary relief or complement surgical intervention. Acetazolamide and furosemide (medications that reduce fluid production) may help lower CSF production in specific cases. Serial lumbar punctures (using a needle to remove small amounts of CSF from the lower back) can temporarily relieve pressure in premature infants or act as a bridge to surgery. Symptom management, including pain relief and anti-nausea medications, may be used while awaiting definitive treatment.

Contemporary Surgical Techniques

Neuronavigation systems (computer-guided mapping technology) provide real-time, three-dimensional guidance during surgery, which can assist in precision and procedural planning. Endoscopic techniques allow direct visualisation of the ventricles, aiding treatment of complex cases. In some situations, combined procedures, such as ETV with choroid plexus cauterisation (reducing CSF production), are used. Revision surgeries address shunt malfunctions or infections if they occur.

Post-Treatment Monitoring

Long-term follow-up is important for hydrocephalus patients to monitor progress and identify potential issues early.

Regular imaging studies (such as CT or MRI scans) track ventricular size and shunt position
Neurological assessments evaluate symptom changes and detect potential complications
Shunt adjustments allow our neurosurgeon to modify CSF drainage as patients grow or as their condition changes

Every patient’s condition is unique.

Our neurosurgeon will assess your specific situation and recommend an appropriate treatment approach for you.

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Complications if Left Untreated

Untreated hydrocephalus may pose risks to brain function and overall health. Persistent pressure from excess CSF can progressively affect brain tissue, potentially leading to neurological deficits (problems with brain and nerve function). In infants, this may result in developmental disabilities, including intellectual impairment, cerebral palsy (a condition affecting movement and posture), and visual impairment.

Adults with untreated hydrocephalus may face progressive cognitive decline (a gradual worsening of thinking and memory abilities), which can affect independence in daily activities. Gait disturbances (difficulty walking) may worsen over time, increasing the risk of falls and related injuries. Urinary incontinence (loss of bladder control) may become persistent and impact quality of life and social functioning.

In more severe cases, prolonged elevation of intracranial pressure (pressure inside the skull) can lead to serious complications, including brain herniation, a medical emergency where brain tissue shifts from its normal position. Chronic papilledema (swelling of the optic nerve, which connects the eye to the brain) may result in permanent vision impairment. Seizures may develop or become more difficult to manage. In acute cases, untreated hydrocephalus can be life-threatening.

The psychological impact on patients and families can also be significant. Personality changes, depression, and anxiety may occur as the condition progresses. Understanding these potential risks underscores the importance of timely medical evaluation and appropriate management. Early treatment may help reduce the likelihood of complications and support neurological function.

Prevention

While not all cases of hydrocephalus are preventable, certain measures may help reduce risk. Pregnant women are encouraged to attend regular prenatal care. This includes folic acid supplementation before conception and during early pregnancy, which may reduce the risk of neural tube defects. Avoiding infections during pregnancy through proper hygiene and recommended vaccinations may also help reduce the risk of congenital hydrocephalus.

Protecting against head injuries is important throughout life. Using appropriate car seats for children, wearing helmets during sports activities, and implementing fall prevention measures for older adults may help lower the risk of traumatic brain injuries. Creating safer home environments can further reduce injury risk.

Timely treatment of central nervous system infections (infections affecting the brain and spinal cord) may help reduce the likelihood of secondary hydrocephalus. Medical attention should be sought for symptoms of meningitis (inflammation of the protective membranes around the brain) or encephalitis (inflammation of the brain ), such as severe headache, fever, or neck stiffness. Adhering to recommended vaccination schedules may offer protection against infections associated with hydrocephalus.

Managing underlying medical conditions may help reduce the risk of acquired hydrocephalus. This includes regular monitoring of brain tumours or cysts, managing blood pressure to reduce the risk of brain haemorrhage (bleeding), and following post-operative care instructions after neurosurgical procedures.

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Frequently Asked Questions

Is hydrocephalus hereditary?

Most cases of hydrocephalus are not directly inherited. However, certain genetic conditions can increase risk. Some rare forms follow genetic patterns, particularly those associated with neural tube defects (birth defects affecting the brain and spine) or specific syndromes. Families with a history of hydrocephalus or spina bifida may have a slightly increased risk. Genetic counselling can help families understand their particular situation and plan appropriately. Most cases of hydrocephalus occur sporadically, without a family history.

Can people with hydrocephalus lead normal lives?

With proper treatment and management, many individuals with hydrocephalus can lead fulfilling, productive lives. Outcomes depend on early diagnosis, appropriate treatment, and regular medical follow-up. Children who receive timely treatment often attend regular schools and participate in everyday activities. Adults may maintain careers, relationships, and independence. While some may experience mild ongoing challenges, modern treatments aim to improve long-term outcomes. Regular monitoring helps healthcare professionals identify any complications early so they can be addressed promptly.

How long does a shunt last?

Shunt lifespan varies considerably among patients. Some shunts function properly for decades. Others may require revision within months or years. Paediatric patients typically need revisions as they grow. Factors affecting shunt longevity include patient age, hydrocephalus type, and infection prevention. Modern shunt designs and surgical techniques continue to improve durability. Regular follow-up helps detect problems early, often before symptoms develop.

What are the signs of shunt malfunction?

Shunt malfunction symptoms often mirror original hydrocephalus symptoms. Common signs include:

Recurring headaches (primarily upon waking)
Nausea and vomiting
Vision changes
Decreased alertness

In children, irritability, poor feeding, and regression of developmental milestones may occur. Some patients experience abdominal pain if the tube placed in the abdomen is problematic. Redness or swelling along the shunt tract suggests infection. Any combination of these symptoms warrants immediate medical evaluation. Early detection and treatment of shunt problems can help prevent serious complications.

Is hydrocephalus surgery risky?

Like all neurosurgical procedures, hydrocephalus surgery carries some risks, though modern techniques aim to improve safety. Potential complications include infection, bleeding, and shunt malfunction. However, the risks of untreated hydrocephalus may exceed surgical risks. Qualified healthcare professionals using established techniques aim to minimise complications. Pre-operative planning, sterile techniques, and antibiotic protocols can help reduce infection risk. Many patients tolerate surgery well and may experience symptom improvement. Our neurosurgeon will discuss specific risks and benefits based on your individual condition and health situation.

Can hydrocephalus develop in adults without warning?

Yes, hydrocephalus can develop in adults at any age, sometimes with subtle initial symptoms. Normal pressure hydrocephalus typically affects older adults and progresses gradually. Acquired hydrocephalus from tumours, bleeding, or infections can develop more suddenly. Early symptoms like mild memory problems or slight gait changes are often attributed to ageing or other conditions. This highlights the importance of seeking medical evaluation for persistent neurological symptoms (such as ongoing headaches, balance problems, or changes in thinking). Early diagnosis enables treatment before significant brain damage occurs.

What follow-up care is needed after treatment?

Long-term follow-up is essential for all hydrocephalus patients. Initially, appointments may occur every few months to monitor recovery and shunt function. As patients stabilise, visits may be reduced to once a year. Follow-up includes:

Neurological examinations
Imaging studies (such as CT or MRI scans) to assess ventricular size
Shunt adjustments if needed

Patients learn to recognise potential complications requiring immediate attention. Children require additional monitoring for developmental progress. This ongoing care helps healthcare professionals monitor your condition and intervene early if problems arise. Maintain regular follow-up appointments, even when feeling well.

Conclusion

Hydrocephalus is a neurological condition that can affect individuals of all ages. Understanding the symptoms and seeking timely medical evaluation may help improve outcomes and quality of life. Surgical techniques, including shunt systems and minimally invasive procedures, can offer tailored treatment approaches for each patient’s specific needs.

Early recognition and intervention may be important factors in management. Whether dealing with congenital hydrocephalus in infants or normal pressure hydrocephalus in elderly patients, prompt assessment aims to help prevent further neurological damage and support function. With appropriate care and regular monitoring, many patients with hydrocephalus may experience symptom improvement.

If you or a loved one is experiencing symptoms of hydrocephalus, speak with our Senior Consultant Neurosurgeon about evaluation and treatment options.

An individualised assessment can help determine the most appropriate approach for your condition.

Book Your Consultation Today

Dr Teo Kejia 张哿佳医生

Senior Consultant Neurosurgeon

MBBS (SG)●MRCS (Edin)●FAMS●FRCS Ed●IFAANS

Dr Teo Kejia is an experienced Senior Consultant Neurosurgeon and Director at Precision Neurosurgery.

Dr Teo has extensive knowledge and experience in the field of neurosurgery, with a particular focus on complex brain tumour procedures. He is adept in employing advanced surgical techniques, including brain mapping and awake brain surgery, especially for treating gliomas and glioblastomas. His expertise extends to neuro-oncology, encompassing both brain and spinal tumours, as well as neurovascular and skull base surgery.

Additionally, Dr Teo offers treatment for a range of neurological conditions, such as traumatic head injuries, intracerebral aneurysms, and degenerative spine disorders, which include neck and back pain. He is also proficient in managing ischemic and haemorrhagic strokes, hydrocephalus, trigeminal neuralgia, and hemifacial spasm.

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