Which signs or symptoms occur and their severity relates to the rapidity of onset of the hydrocephalus and whether alternative pathways are available. Interestingly, most infants do not develop papilledema. This is due in part to open sutures, but mostly to the increased compliance of their unmyelinated brains. As ventriculomegaly may be the only finding of hydrocephalus in the preterm infant, routine cranial ultrasound imaging of this patient population is essential. The older child presents in a different manner because of closed sutures, a myelinated, non-compliant brain and the ability to vocalize discomfort.
Headaches are the most common symptom followed by vomiting.
Vomiting is often in the morning as the intracranial pressure is increased by the recumbent position and because of the hypoventilation that occurs during sleep. Papilledema is common in the older child, especially if there is chronic pressure due to slowly developing hydrocephalus. A more unusual presentation is the older child or adolescent who presents with a deterioration in school performance, infrequent nausea and vomiting, papilledema and a massively enlarged head. An MRI reveals hydrocephalus with dilation of the third and lateral ventricles but a normal sized fourth ventricle, a pattern consistent with aqueductal stenosis. Certainly the large head would indicate the hydrocephalus had been present for a long period and the acute or subacute deterioration was due to a loss of some compensatory mechanism that had been holding the system in balance.