Congenital Hydrocephalus vs. Subdural Hematoma
Left picture: The diagnosis is a shunted hydrocephalus without a recognizable macrocephaly; nevertheless, a chronic shunt dysfunction must be excluded due to the ocular findings. Right picture: This child has a chronic subdural hematoma following an incidental injury. In case of a clinically not obvious macrocephaly, eye signs such as abducens nerve paresis, setting sun sign, papilledema, and strabismus may point to an active hydrocephalus in addition to the data of measurement of head circumference, but also to a chronic subdural hematoma. In the latter pathology a squared skull may be a characteristic sign. In addition, anamnestic, clinical and radiological findings may be present which belong to an incidental injury (battered child syndrome).
In both pathologies the ocular findings attract attention to begin with. Left picture: It shows a convergent strabismus and a suggested setting sun sign. The face is otherwise inconspicuous. Right picture: The eyelid is closed on the left side. Remarkable are distinct frontal protruberances, a slight squared (box-like) configuration of the skull (caput quadratum), and a lachrymose face.