Signs and symptoms of hydrocephalus

In babies (birth to about 2 years)

A baby's skull bones are not yet fused. The soft spots between them — the fontanelles — give the skull some room to expand when pressure rises. That is why the most visible sign of hydrocephalus in an infant is a head that grows faster than expected.

Pediatricians measure head circumference at every well-child visit for exactly this reason. A head that crosses upward on the growth curve is one of the most reliable early signs.

Other signs that parents and clinicians watch for in babies include:

• A bulging or unusually tense fontanelle (the soft spot)
• Prominent veins visible on the scalp
• A high-pitched cry, irritability, or unusual sleepiness
• Poor feeding or unexplained vomiting
• Eyes that appear to look downward, with the white of the eye visible above the iris (sometimes called "sunsetting eyes")
• Delays in reaching expected developmental milestones

None of these signs alone confirms hydrocephalus. A pediatrician, family doctor, or pediatric neurosurgeon puts the picture together based on the exam, the head size trend, and — when needed — imaging.

In older children

Once the skull bones have fused (usually after about age 2), the head can no longer enlarge to make room for extra fluid. Pressure inside the head rises instead. The signs shift.

In older children and teenagers, hydrocephalus may show up as:

• Headaches, often worse in the morning or that wake the child from sleep
• Nausea or vomiting, sometimes without a stomach bug behind it
• Vision changes — blurred or double vision, or eyes that don't move together normally
• Trouble with balance, coordination, or walking
• New problems with concentration, school performance, or memory
• Changes in personality, mood, or energy level
• Tiredness that doesn't match how much sleep they're getting

For a child who already has a shunt, families and care teams also watch for any return of the symptoms that brought them to the doctor in the first place. A new pattern of headaches, vomiting, or sleepiness in a child with a shunt is something to bring to the neurosurgery team.

In adults with acquired hydrocephalus

When hydrocephalus develops in an adult — often after a head injury, a brain hemorrhage, an infection, or a tumor — the signs overlap with those in older children, but tend to be more obvious because the skull cannot expand at all. Common signs include:

• Headache, often persistent or worse in the morning
• Nausea and vomiting
• Blurred or double vision
• Balance and coordination problems
• Tiredness, sleepiness, or sluggish thinking
• Changes in personality, judgment, or memory

The pace at which these symptoms appear depends on the cause. Hydrocephalus that follows a brain bleed may come on within days. Hydrocephalus that follows a tumor may appear gradually over weeks or months.

In adults with normal pressure hydrocephalus (NPH)

NPH usually appears in adults over 60 and progresses slowly. It is one of the most under-recognized causes of new walking trouble and new thinking problems in older adults. Many people with NPH are first told they have Alzheimer's disease, Parkinson's disease, or "just aging."

NPH has three classic signs. Not everyone has all three, and they often appear in a particular order.

NPH is important to recognize because it is one of the few causes of dementia-like symptoms that can sometimes be helped by a procedure. If you or a family member is showing this pattern — particularly the walking changes — it is worth raising NPH as a possibility with a doctor.

In people who already have a shunt

Shunts can stop working. When they do, the symptoms that brought a person to surgery in the first place often come back. Families and care teams who live with a shunt long-term get to know what is normal for that person and what is worth a call. Common signs of a shunt that may not be working well include:

• The return of headaches, especially the morning headaches that the shunt was placed to relieve
• New nausea or vomiting
• Increased sleepiness, irritability, or confusion
• Vision changes
• In babies, a bulging fontanelle and rapid head growth
• Swelling, redness, or pain along the path of the shunt under the skin
• Fever along with any of the above (a possible sign of shunt infection)

Anyone living with a shunt should have a neurosurgery team they can reach — and a clear plan with that team about what to do if symptoms change.

What to discuss with a doctor

This page is here to help you recognize patterns. It cannot replace a clinical exam. If you or someone you care for has signs that fit the descriptions above, the next step is talking to a doctor — your primary care doctor, your child's pediatrician, or, if you already have one, your neurosurgery team.

A few things tend to be useful in those conversations:

• When the symptoms started, and whether they have changed
• Whether anything makes them better or worse (time of day, position, activity)
• For families with babies: the recent head circumference numbers from well-child visits
• For older adults: any new trouble with walking, even if it feels small
• For people with a shunt: when it was placed, by whom, what type, and what the original symptoms were

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