Clinical Practice and Cases in Emergency Medicine

Introduction: Hydrocephalus presents a diagnostic and therapeutic challenge due to its diverse clinical manifestations and underlying causes. Symptoms can vary from feelings of unsteadiness to focal symptoms such as weakness, difficulty ambulating, or urinary incontinence. Due to the wide variety of symptoms, hydrocephalus can present a difficult diagnosis for any physician and may require different interventions depending on the underlying cause.

Case Report: This case report highlights a 69-year-old female with altered mental status, initially diagnosed with communicating hydrocephalus and sepsis. The patient’s symptoms, including confusion, urinary dysfunction, and gait ataxia, initially masked the hydrocephalus, emphasizing the importance of considering this condition in patients with prolonged progression of neurological deficits. Brain imaging, including magnetic resonance imaging (MRI) and computed tomography (CT), facilitated the diagnosis, suggesting hydrocephalus with downward tonsillar herniation. The acute management involved empirical antibiotic therapy for associated sepsis, followed by the placement of an external ventricular drain for cerebrospinal fluid diversion and sampling, including cytology and cell counts, given the concern for tonsillar herniation with a lumbar puncture. Cine MRI and CT cisternogram demonstrated a cyst filling the volume of the fourth ventricle. Subsequent surgical fenestration of the cyst using a suboccipital craniotomy for cyst resection alleviated symptoms and stabilized ventricular size.

Conclusion: Hydrocephalus can present with unique and varying symptoms, and it can have a variety of underlying causes. This case underscores the necessity for individualized treatment approaches tailored to the underlying etiology of hydrocephalus, including temporizing measures and more aggressive approaches once infection has improved.