A 14-Month-Old Girl with Recurrent Vomiting

Background: Hydrocephalus is an abnormal accumulation of cerebrospinal fluid (CSF) in the brain's ventricles. As the ventricles enlarge, brain pressure increases, leading to cognitive difficulties, impaired vision, delayed development, and death. Epidemiologic studies estimate a yearly average of 6,000 hydrocephalus cases in newborns. Case Presentation: A 14 month and 19-day old female infant suffered recurrent episodes of vomiting. The first episode occurred at age 11 months and 12 days. The emergency room (ER) diagnosis was viral gastroenteritis; vomiting resolved with supportive care and antiemetic medication. The following two months she returned to the ER three times for recurrent vomiting. On the last ER visit, her parents reported developmental regression during the previous three months. Examination findings included frontal bossing, full fontanelle with visible pulsations, enlarged head circumference (>95th percentile), and signs of pyramidal tract dysfunction. Magnetic resonance imaging showed enlargement of the lateral and third ventricles with cerebral aqueduct stenosis. No masses or lesions were noted. In this case, the rapid increase in head circumference, developmental regression, and imaging results was key to the diagnosis of increased intracranial pressure due to aqueductal stenosis with hydrocephalus. Therapies for hydrocephalus include shunts and endoscopic third ventriculostomy (ETV). This patient was successfully treated with an ETV, creating an opening in the third ventricle to drain excess CSF. Untreated, hydrocephalus could have caused further developmental regression, brain damage, and even death. Conclusions: This case illustrates the importance of primary care continuity, tracking developmental milestones and head circumference using growth charts.