Macrocephaly
Time
Good, Washed
I've been asked
Position, Pain
Exposure
Equip
Well (Alert, no stridor, WOB, cyanosis, parlour, or jaundice)
Growth
Obs
Dysmorph
NC stigmata
HC
Parents HC (Father 97th = 58@150cm + 1cm for every extra 11cm), Mother 97th = 56@140 + 1cm for every additional 12cm)
Serial
Head shape: craniosynostosis, biparietal diameter, AP diameter, frontal bossing, occipital prominence
Titubation (head tremor): cerebellar
Truncal ataxia (cerebellar including Dandy Walker syndrome)
Head
- Sutures (PF @ 4mo, AF @ 18mo)
- Fontanelle pressure while sitting
- VP
- Auscultate eyes, temporal fossa, mastoids (AVM)
Prominent scalp veins
Cushing's triad (bradypnoea, bradycardia, hypertension)
Paralysis of upwards gaze, Parinaud syndrome, ICP (cf lid lag (static lid not covering iris, eye in downward gaze), von Grafe's sign (dynamic, lid not keeping up with iris on down movement, lagophthalmos (can't close)
Lateral gaze (lateral rectus aka 6th nerve palsy with hydrocephalus)
Papilloedema
CN
Eye exam
Lower then upper (Hydrocephalus affects lower then upper)
- Motor
- Cerebellar
- (Sensation if spinabifida)
Abdomen
- VP shunt insertion scars
- hepatosplenomegaly (storage disorders)
Developmental assessment
Add 13.5
DDx
Familial large head
Large bones
- Bone Expansion
- Rickets
- OI
- Marrow Expansion
- Chronic haemolytic anaemias
- Generalised megalencephaly
- Sotos
- Weaver
- Neurocutaneous (NF, TS, SW)
- Metabolic: lipidoses, mucopolysaccharidoses, leucodystrophies
- Localised
- Tumour: gliomas (astrocytoma, ependymoma), medulloblastoma
- Abscess
- non-communicating aka obstructive
- aqueduct stenosis (between 3rd/4th vent)
- Dandy walker
- tumour
- acute periventricular bleed
- aqueduct stenosis (between 3rd/4th vent)
- communicating
- overproduction: choroid plexus papilloma
- underabsorption: meningeal adhesions/fibrosis post meningitis/bleed, cranial venous congestion
- Chiari / spina bifida ? where does this fit
- subdural: accident, NAI
NB Achondroplasia is a combination. Frontal bossing, mild megalencephaly then can develop communicating hydrocephalus (venous congestion due to small foreman magnum, usually the disproportion between the foramen and contents is maximal at 12mo)
Ix
HUSS if fontanelle open
CT/MRI depending on stability
Complications dependent on cause
Developmental delay
Centiles for adult head circumference. K M Bushby, T Cole, J N Matthews, and J A Goodship Arch Dis Child. 1992 Oct; 67(10): 1286–1287.