Hydrocephalus is an abnormal buildup of cerebrospinal fluid (CSF) in or around the brain. The extra fluid can raise pressure and injure a developing brain, so suspected symptoms need prompt medical assessment. Treatment is usually surgery, either a drainage shunt or, for selected cases of obstructed CSF flow, an endoscopic third ventriculostomy (ETV).
A large head by itself does not diagnose hydrocephalus. Doctors look at head-growth patterns, the child’s examination and brain imaging, then identify the cause and choose treatment based on age, anatomy, the type of CSF-flow problem and the child’s overall condition.
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What hydrocephalus means
CSF is a clear fluid that cushions the brain and spinal cord, carries nutrients and removes waste. It is continuously produced, circulates through spaces called ventricles and is then absorbed into the bloodstream. Hydrocephalus develops when CSF production, circulation or absorption is out of balance. Fluid enlarges the ventricles and may increase pressure on brain tissue.
In babies, the skull bones have not fully fused, so pressure can make the head enlarge rapidly. In older children, the skull cannot expand as easily; pressure may instead cause headaches, vomiting, visual symptoms, sleepiness or changes in coordination and behavior. Untreated pressure can damage the developing brain, which is why clinicians treat suspected hydrocephalus urgently rather than waiting for symptoms to resolve.
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What causes hydrocephalus in a baby or child?
Hydrocephalus can be present before birth (congenital) or develop later (acquired). Some children have more than one contributing problem, and in some cases no cause is found despite investigation.
Congenital causes
- Spina bifida: spinal-cord and skull-development abnormalities can interfere with normal CSF circulation.
- Prematurity-related bleeding: bleeding into or around the brain can obstruct CSF pathways or impair absorption. The risk is linked to the bleeding and its effects, not simply to being born early.
- X-linked hydrocephalus: an inherited form associated with a gene on the X chromosome; genetic counseling may be offered when the pattern suggests it.
- Dandy-Walker malformation: a developmental abnormality involving the cerebellum and spaces at the back of the brain.
- Arachnoid cysts and other structural differences: a cyst or narrowed channel can block CSF flow.
Congenital hydrocephalus may be detected on a routine pregnancy ultrasound or shortly after birth. A prenatal finding does not by itself predict a child’s future abilities; the underlying brain development, associated conditions and later response to treatment matter.
Acquired causes
- Bleeding in the brain, including bleeding after an injury or from a blood-vessel problem.
- Venous thrombosis, in which a clot blocks drainage from the brain.
- Meningitis or another infection that inflames the tissues through which CSF is absorbed.
- Brain tumors or other masses that obstruct CSF pathways.
- Head injury or stroke that disrupts circulation or absorption.
MedlinePlus and the NHS list injuries, strokes, infections, tumors and bleeding among acquired causes. Even after detailed imaging, clinicians sometimes cannot identify a single cause.
Warning signs by age
Symptoms vary with the child’s age, how quickly pressure is changing and the underlying cause. A symptom can have many explanations; only a clinician can determine whether hydrocephalus is present.
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Babies and young infants
- Head size that increases unusually quickly or crosses growth-chart percentiles.
- A tense or bulging fontanelle (the soft spot), especially when the baby is calm and upright.
- A thin, shiny scalp with unusually visible veins.
- Eyes that look persistently downward (“sunsetting” eyes).
- Poor feeding, repeated vomiting, unusual irritability or marked sleepiness.
- Stiffness, spasms or reduced movement of the legs.
Some babies have few obvious symptoms at first. A midwife, pediatrician or health visitor may notice a concerning head-growth pattern before parents see other changes.
Older babies, children and teenagers
- Headaches, often worse on waking or after lying down.
- Nausea or vomiting without a clear stomach illness.
- Blurred or double vision, abnormal eye movements or other visual changes.
- Increasing sleepiness, confusion, irritability or a noticeable change in school or everyday functioning.
- Difficulty walking, poor balance or new clumsiness.
- New loss of bladder control or other neurological changes.
Symptoms that are sudden, severe or progressively worsening require same-day medical advice. A child who is difficult to wake, has a seizure, has repeated projectile vomiting or has trouble breathing needs emergency services.
Is a large head always hydrocephalus?
No. Some babies have familial macrocephaly (a naturally larger head), and head size can be influenced by normal variation, birth-related molding or other conditions. Doctors compare measurements over time, examine the fontanelle and neurological status, and review development. Rapid acceleration of head growth, a bulging fontanelle or neurological symptoms make imaging more urgent. A normal-looking head does not exclude hydrocephalus in an older child, because pressure may develop without skull enlargement.
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Clinical examination and history
The clinician records pregnancy and birth history, prematurity or bleeding, infections, injuries, headaches, vomiting, vision and walking changes. For infants, serial head measurements are plotted on a growth chart. The examination includes the fontanelle, eye movements, muscle tone, reflexes, alertness and development.
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Imaging before and after birth
- Pregnancy ultrasound: can show enlarged ventricles or other structural findings during prenatal care.
- Fetal MRI: provides a more detailed view of the fetal brain when ultrasound raises questions and can help identify a cause, as described by Children’s Hospital of Philadelphia.
- Ultrasound through the fontanelle: in a young infant whose soft spot is open, this can provide an initial view without radiation.
- CT: is fast and can show fluid buildup, enlarged ventricles, pressure effects and structural defects; radiation exposure is considered when deciding whether it is needed.
- MRI: gives detailed images of brain structures and CSF pathways without ionizing radiation, although young children may need measures to keep them still.
Imaging confirms whether ventricles are enlarged and helps distinguish obstructed CSF flow from other patterns. The scan must be interpreted alongside symptoms and examination; an enlarged ventricle alone does not determine the treatment.
Treatment: why surgery is usually needed
The NHS states: “Hydrocephalus (excess fluid in the brain) is treated with surgery.” The aim is to lower pressure, protect brain tissue and restore a workable route for CSF. Doctors may monitor selected children with stable, mild findings, but observation requires a defined follow-up plan and repeat examinations or imaging.
CSF shunt surgery
A shunt is a system of tubing and a valve that diverts CSF from a brain ventricle to another body area where it can be absorbed. A ventriculoperitoneal (VP) shunt drains into the abdomen and is the most common arrangement; other destinations may be considered when the abdomen is unsuitable. The valve regulates flow and may be adjustable or fixed, depending on the device and clinical plan.
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Shunt surgery can relieve pressure quickly, but the child has an implanted device that may need revision as the child grows or if a component fails. Blockage and infection are the principal complications. A shunt can also drain too much or too little fluid, causing symptoms that require specialist assessment.
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Endoscopic third ventriculostomy (ETV)
During ETV, a neurosurgeon uses an endoscope to create an opening in the floor of the third ventricle. CSF then bypasses an obstruction and reaches spaces where it can be absorbed. ETV is mainly considered for obstructive hydrocephalus and is not suitable for every child. Age, the exact anatomy on MRI, previous infections or bleeding and the brain’s ability to absorb CSF all affect the decision.
ETV avoids a permanent implanted shunt and generally has a lower infection risk than shunt surgery. The opening can narrow or close, however, sometimes months or years later. Closure can cause a rapid return of pressure and may require repeat ETV or later shunt placement, so families need an emergency plan even after a successful procedure.
Shunt and ETV compared
| Decision factor | Shunt | ETV |
|---|---|---|
| Best fit | Many forms of hydrocephalus, including cases in which CSF cannot be absorbed adequately | Selected obstructive (blocked-flow) hydrocephalus with suitable anatomy |
| Implanted hardware | Yes: catheter, valve and drainage tubing | No permanent shunt hardware |
| Infection considerations | Implanted hardware can become infected | Lower infection risk than shunt surgery, according to NHS guidance |
| How failure presents | Blockage, disconnection, breakage or infection can stop or alter drainage | The ventricular opening can close and obstructive symptoms can return |
| Later procedures | Revision may be needed during childhood | Repeat ETV or later shunt may be needed if the opening closes or absorption is inadequate |
There is no universally superior operation. The neurosurgical team balances the cause, age, anatomy, previous treatment, infection history and urgency of pressure relief.
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Recovery, monitoring and everyday care
After surgery, the team checks alertness, eye movements, movement, feeding, pain and the wound. The hospital stay varies with the operation and the child’s condition. At home, follow the discharge instructions for wound care, activity, bathing and medicines, and attend scheduled neurosurgery and developmental follow-up.
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Keep a record of the child’s baseline behavior, appetite, sleep, balance and vision. A gradual change can be easier to recognize when compared with that baseline. Infants may need repeated head measurements; older children may need developmental, educational, vision or physical-therapy support depending on the cause and any brain injury that occurred before treatment.
Recognizing shunt or ETV problems
Possible shunt blockage or infection
Contact the child’s neurosurgical team immediately for redness, swelling or tenderness along the shunt track; fever; worsening headache; repeated vomiting; neck stiffness; abdominal pain or swelling; or unusual irritability, sleepiness or poor feeding in a baby. These symptoms can also have less serious causes, but a child with a shunt must be assessed promptly because blockage or infection can raise pressure and injure the brain.
Possible ETV closure
Return of the original pressure symptoms—morning headache, vomiting, visual changes, sleepiness, confusion or worsening balance—can indicate that the opening has narrowed or closed. Treat this as urgent, particularly when symptoms progress quickly. Do not wait for a routine appointment.
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Ask the treating team whether the child should carry a hydrocephalus shunt alert card. The NHS notes that an alert card tells emergency clinicians a shunt is present and can speed recognition of relevant history. It is an identification aid, not a treatment and does not prevent malfunction.
What determines outlook?
Outcome varies widely. Important factors include the cause of hydrocephalus, how early pressure was relieved, the child’s age and brain development, associated conditions such as spina bifida or infection, complications from bleeding or injury, and response to treatment. Some children require multiple operations or long-term monitoring; others remain stable after one procedure. Prognosis cannot be estimated from head size or the need for a particular operation alone.
Families should ask the care team which symptoms warrant emergency help, who is available after hours, how follow-up imaging will be scheduled and what developmental services are appropriate. If you think your child may have hydrocephalus, the NHS advises: “Call a GP or use NHS 111 if you think you or your child may have symptoms of hydrocephalus.” Use local emergency services instead when the child is difficult to wake, has a seizure, severe breathing problems or rapidly worsening symptoms.
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