🧠 MOCK OSCE · FCPS, MCPS, MD PAEDIATRICS ⏱ 10 min · HYDROCEPHALUS

Hydrocephalus · Short Case

Candidate task: perform focused examination on a child with suspected hydrocephalus.
Then discuss differential diagnosis, investigations, management & follow‑up.
Pre‑exam Protocol
⏤ · Wash, Warm, Introduce, Position, Expose, Approach ▾

Standard pre‑examination protocol – must be demonstrated:

🖐 Wash hands with sterilizing solution.
🔥 Warm hands and stethoscope.
👋 Introduce yourself to child & parent.
🧍 Position child: supine, then sitting.
👕 Exposure — allow full examination.
➡️ Approach from the right side.
✔ CPSP marker: Pre‑exam Protocol is observed and scored.
1. Clinical Examination (≈6 min)
02 General Look (Inspection from end of bed) ▾

Key observations:

  • Head size: enlarged occipitofrontal circumference (OFC) – plot on growth chart.
  • Head shape: frontal bossing, prominent occiput (Dandy‑Walker), foreshortened occiput (Chiari).
  • Fontanelles: tense, bulging, delayed closure.
  • Scalp veins: prominent, distended.
  • Eye signs: setting‑sun sign (downward deviation), squint, nystagmus.
  • Skin: neurocutaneous stigmata (NF, Sturge‑Weber).
  • Back: midline defects (myelomeningocele, sinus).
  • Gait: ataxia, spasticity (lower limbs).
👁 Red flags: rapidly increasing head circumference, bulging fontanelle, setting‑sun sign, vomiting, lethargy, papilledema → raised ICP.
03 Focused Examination ▾

Systematic head & neurological exam:

  • Head circumference: measure and plot on appropriate growth chart. Note rate of growth (accelerated).
  • Parental head circumferences: for comparison (familial macrocephaly).
  • Fontanelles: anterior (size, tension – bulging indicates raised ICP), posterior (closed by 6‑8 weeks).
  • Sutures: separated (raised ICP), ridging (craniosynostosis).
  • Transillumination: positive in hydrocephalus (if thin cortical mantle).
  • Auscultation: cranial bruits (AVM, vein of Galen – rare).
  • Percussion: cracked‑pot sound (Macewen sign) – raised ICP with separated sutures.
  • Fundoscopy: papilledema (raised ICP), optic atrophy (chronic).
  • Eye movements: setting‑sun sign (hydrocephalus), 6th nerve palsy (raised ICP).
  • Motor: spasticity (especially lower limbs), brisk reflexes, clonus, extensor plantars.
  • Gait: ataxia, wide‑based (posterior fossa involvement).
  • Shunt assessment: palpate shunt tract, check for reservoir, infection (erythema, tenderness).
🔍 Key: hydrocephalus = impaired CSF circulation/absorption → ventricular dilation → raised ICP.
04 General Physical Exam (Hands → Face → Chest → Abdomen → Limbs) ▾

Systematic examination:

  • Hands: clubbing (cyanotic heart disease – rare), syndactyly (Apert).
  • Face: dysmorphism (syndromic causes), facial asymmetry.
  • Eyes: fundoscopy, squint, nystagmus.
  • Chest: cardiac murmur (if syndromic), respiratory effort.
  • Abdomen: VP shunt tubing, hepatosplenomegaly (storage disorders – rare).
  • Back: midline defects (myelomeningocele, dermal sinus, hairy patch).
  • Limbs: spasticity, contractures, deformities.
  • Skin: neurocutaneous stigmata (NF, tuberous sclerosis).
📏 Anthropometry: weight, height, OFC – plot on growth charts. Parental OFC for comparison.
05 Developmental Assessment & Associated Signs ▾

Assess:

  • Motor milestones: delayed (head control, sitting, walking).
  • Cognitive: intellectual disability (if significant brain injury).
  • Speech: delayed.
  • Behaviour: irritability, lethargy, personality change (raised ICP).
  • Associated: seizures (if cortical involvement).
🧠 Red flags: acute deterioration in a child with VP shunt → shunt malfunction.

📋 Case Presentation – (fill in during exam)

This is a _____-year-old _____ child, referred for _____ (large head / vomiting / lethargy / developmental delay). On examination, the child appears _____ (well/unwell), with _____ (head size / shape). Head circumference: _____ cm (_____ percentile). Parental OFC: _____ cm. Fontanelle: _____ (open/closed, tense/bulging). Sutures: _____ (separated/closed). Eye findings: setting‑sun sign _____ (present/absent), fundi _____ (normal / papilledema / optic atrophy). Neurological exam: tone _____ (increased / decreased), reflexes _____ (brisk / normal), plantars _____ (flexor / extensor). Growth: weight _____ percentile, height _____ percentile. Associated signs: _____ (midline back defect, neurocutaneous stigmata, VP shunt).

2. Viva Discussion (≈4 min)
06 Viva · Differential, Investigations, Management, Follow‑up ▾
🔹 Differential Diagnosis

• Communicating hydrocephalus – impaired CSF absorption (post‑meningitis, SAH).
• Non‑communicating (obstructive) – aqueduct stenosis, posterior fossa tumour, Chiari.
• Congenital – aqueduct stenosis, Dandy‑Walker, Chiari II.
• Acquired – post‑meningitis, post‑haemorrhage, tumour.
• Familial macrocephaly – benign, normal development.
• Megalencephaly – Sotos, NF, metabolic (Canavan, Alexander).
• Subdural collections – haematoma, effusion (often after trauma).
• Benign extra‑axial fluid of infancy – resolves by 2 years.
• Vein of Galen malformation – bruit, heart failure.
• Hydranencephaly – absent cerebral hemispheres.

🔹 Investigations – Diagnosis

• Head ultrasound – if fontanelle open (ventricular size, haemorrhage).
• Brain MRI / CT – ventricular dilation, cause (tumour, aqueduct stenosis, Chiari).
• CSF flow studies – MRI CINE (to assess obstruction).
• ICP monitoring – if diagnosis uncertain.

🔹 Investigations – Aetiology

• MRI brain – structural cause (tumour, Chiari, Dandy‑Walker).
• Toxoplasmosis / CMV – congenital infection.
• Genetic testing – if syndromic (L1CAM, etc.).
• LP – if infection (after imaging).
• Ophthalmology – papilledema, fundoscopy.

🔹 Investigations – Exclude Others

• CT / MRI – to differentiate from megalencephaly, subdural.
• EEG – if seizures.
• Metabolic screen – if neurodegenerative.
• Skeletal survey – if skeletal dysplasia.
• TORCH screen – if congenital infection.

🔹 Investigations – Rule Out Complications

• Ophthalmology – visual fields, optic atrophy (raised ICP).
• Shunt series – if VP shunt (malfunction: X‑ray, CT, nuclear medicine shunt patency).
• Psychometric assessment – cognitive function.
• Feeding / swallow – if bulbar involvement (Chiari).
• Endocrine – if hypothalamic involvement (growth hormone, puberty).

🔹 Management – Across Organ Systems

Neurosurgical

VP shunt (ventriculoperitoneal), VA shunt, ETV (endoscopic third ventriculostomy).

Acute Raised ICP

Head elevation, mannitol, hyperventilation (if imminent herniation), emergency shunt.

Medical

Acetazolamide (temporary), furosemide (to reduce CSF production – limited role).

Neurological

Seizure management (if present), spasticity management (baclofen, physiotherapy).

Developmental

Early intervention, physiotherapy, OT, speech therapy, special education.

Ophthalmology

Regular monitoring for papilledema, optic atrophy, visual fields.

Infectious

Shunt infection: IV antibiotics, shunt removal/externalisation, then replacement.

Multidisciplinary

Neurosurgery, neurology, developmental paediatrics, ophthalmology, rehabilitation.

📈 Prognosis

  • Hydrocephalus: good with early treatment; depends on cause and timing.
  • Aqueduct stenosis: good with VP shunt/ETV.
  • Post‑haemorrhagic: variable; may have developmental delay.
  • Post‑meningitic: variable; may have neurological sequelae.
  • Chiari II (with spina bifida): variable; often learning difficulties.
  • Dandy‑Walker: variable; often developmental delay.
  • Normal pressure hydrocephalus: rare in children.

📋 Follow‑up Schedule

  • Post‑shunt: regular neurosurgery (1‑3 monthly initially), then annual.
  • Ophthalmology: 6‑12 monthly (papilledema, visual fields).
  • Developmental: regular developmental paediatrician, physiotherapy, OT.
  • Shunt surveillance: CT / MRI as per protocol (if symptoms).
  • Transition: plan for adult neurosurgery care.
  • Parental education: signs of shunt malfunction (headache, vomiting, lethargy, sunsetting).
💡 Examiner expectation: ability to differentiate communicating vs non‑communicating, identify raised ICP signs, and discuss shunt management. Know the red flags: rapidly increasing head circumference, vomiting, lethargy, sunsetting sign, papilledema. Shunt malfunction = emergency.
📚 Visit paeds.online for more CPSP resources
Mock OSCE · Hydrocephalus · Based on Wyne‑Harris, Nelson & Pediatric Clinical Advisor