Overview

Hydrocephalus is a neurological disorder where there is a buildup of cerebrospinal fluid inside the cavities within the brain. An excess of fluid causes the ventricles to widen which causes pressure on the brain’s tissues.¹ It is important to assess driving in individuals with hydrocephalus since it could cause them to experience depth perception, processing speed, reaction timing, coordination, short-term memory, vision and navigational issues.² 

Understanding hydrocephalus

Types of hydrocephalus 

Congenital hydrocephalus

Congenital hydrocephalus is a buildup of excess cerebrospinal fluid in the brain since birth. The extra fluid increases the pressure on the baby’s brain, which can cause mental and physical problems. Congenital hydrocephalus occurs due to bleeding in the foetus before birth, infections in the birth parent or a genetic condition.³

Acquired hydrocephalus 

This is a type of hydrocephalus that develops at birth or during adulthood due to an injury or disease.⁴ The injury or disease tends to block the absorption of cerebrospinal fluid in the brain, which can also lead to mental and physical disruption.  The buildup of cerebrospinal fluid occurs when the brain does not absorb enough CSF, the flow of CSF through the cerebrospinal system is blocked or if too much CSF is produced.⁵

Normal pressure hydrocephalus (NPH) 

This is a brain disorder where excess CSF accumulates in the brain’s ventricles, causing thinking and reasoning problems, difficulty in walking and loss of bladder control. However, despite the excess fluid found in the brain, it is called ‘normal pressure’ because the CSF pressure measured during a spinal tap is normal.⁶

Symptoms and effects 

Cognitive impairments 

One of the main symptoms of hydrocephalus is a decline in cognitive activity such as thinking skills, remembering, understanding and trouble concentrating so that they are unable to follow instructions. ⁷

Motor function challenges 

Many people may begin to face challenges in motor function from birth if they have hydrocephalus. Some of these challenges include being unable to balance, having difficulty moving in space and being unable to stand and complete tasks.⁸

Visual and perceptual issues

Visual perception is needed for awareness and representation of something via senses, when this becomes damaged it can make it hard for people to plan movements due to the lack of visual representation. Some examples would be difficulty in negotiating obstacle courses, poor handwriting and being clumsy.⁹

Legal and medical guidelines

Medical evaluation requirements 

Neurological assessments 

A neurological exam is done on people with hydrocephalus to assess the muscle condition, movement, well-being and the function of sensory abilities. Some of the exams done on the brain are ultrasound, MRI and CT scans. An ultrasound is done for infants as it is a low-risk procedure. MRI uses radio waves and magnetic fields to produce detailed images of the brain. They show enlarged ventricles caused by the excess of CSF and it can show the cause of hydrocephalus. A CT scan produces cross-sectional views of the brain, however, they show fewer details than MRI scans and are only used for emergency exams. ¹⁰

Cognitive and psychological testing 

Cognitive and psychological testing measures memory, language skills, maths skills and other abilities that are related to mental functioning to help diagnose a patient's condition accurately. These tests often occur with a neuropsychologist and examine memory, attention and one’s ability to name objects to follow verbal and written commands.¹¹

Legal standards and regulations 

National and regional driving laws 

To be fit to drive one must follow the rules on how many hours one can drive and take the relevant breaks. The rules one follows depend on the type of vehicle you’re driving and the country you're driving in. In the UK three main styles of road signs are important. Circular signs are orders that must be followed legally and if they have a red border around then it must not be done. If it is a blue circle then it will give an instruction and speed limits are also shown in a circle. Triangular signs give warnings and have a red border around the edge to highlight the danger. Rectangular signs give information and on motorways, they are blue, on primary roads they are green and on minor roads they're white.¹²

Licensing requirements and restrictions

There are several documents one needs to present to be able to drive on the UK roads. One of them is a driving licence, if one has a provisional licence then they cannot drive without a person with a qualified driving licence in the car. If one has a driving licence for an automatic then they cannot drive a manual car. Moreover, the vehicle needs to be insured for third-party cover and the driver of the vehicle needs to be a named party on the insurance policy and have their policy so they can drive other cars. A valid MOT is also needed for any vehicle that is over three years old. The vehicle also has to be taxed before it can drive on the road, it is known as a road tax.¹³

Reporting and disclosure 

Physician’s role in reporting 

Furthermore, one must inform DVLA about a medical condition that will affect their driving, in this case, it would be informing about hydrocephalus. Failure to do so can end up in a fine of up to £1000. If one holds a motorcycle or car licence then they must tell DVLA about the hydrocephalus symptoms and fill in a B1 form. However, if they have hydrocephalus without symptoms then DVLA don't need to know about the condition. If one has a bus, coach or lorry licence then they must tell DVLA and fill out a B1V form.¹⁴

Management and support strategies

Treatment and management of hydrocephalus 

Shunt placement and monitoring 

This procedure is done to lower the pressure and bring it back to a normal range, so a shunt is placed inside the brain’s ventricles. The shunt is placed in the lateral ventricles, in the centre of the brain where the CSF fluid is produced. Then a hole is drilled into the skull and a proximal catheter tube is put through the brain into the ventricle. The tube is connected to a valve placed behind the ear and the valve regulates the pressure by controlling how much fluid is allowed out of the brain to flow the shunt tubing.¹⁵

Medications and therapies 

Another treatment for hydrocephalus is an endoscopic ventriculostomy where the surgeon uses a small video camera to see inside the brain. Then the surgeon makes a hole in the bottom of a ventricle and allows the cerebrospinal fluid to flow out of the brain. However, some people may need supportive therapy such as occupational therapists, who specialise in therapy to develop everyday skills, and mental health professionals such as psychologists or psychiatrists.¹⁶

Adaptive strategies for driving 

Use of assistive devices

To ensure safe driving for people with hydrocephalus they may use assistive apps such as Hydro assist which allows people to record and store their hydrocephalus treatment history and access it when needed. It allows one to store medical and emergency contacts for easy communication and to store information about the condition.¹⁷

Vehicle modifications

Some adaptations that can be made to assist people with hydrocephalus such as swivel seats and hand controls.¹⁸ Swivel seats help people get in and out of the car more easily such as some come right out of the car and lift to help get on their feet. Hand controls allow one to drive an automatic car to be driven without using foot pedals and allow the driver to steer using the left hand and to accelerate and brake using the right hand.¹⁹ 

Safety considerations

Recognising warning signs 

Changes in symptoms 

One must be able to understand the signs and symptoms of shunt failure, however, these symptoms do vary from person to person but recurring failures have similar symptoms. It is important to consult a physician immediately if one experiences these symptoms. It is also important to take a rest while driving with hydrocephalus, approximately 15 to 30 minutes of break.²⁰

Emergency preparedness

Having a plan in case of medical emergencies 

It is important one has a copy of medical records and medical alert ID with them as in case of emergencies someone can identify their identity quickly in extreme circumstances. It is also important to keep emergency contact saved on phones in case of emergency so someone can be informed quickly. 

Lifestyle adjustments 

It is also important to stay active for overall health. It can help improve physical and mental health. Some exercises people with hydrocephalus do are boxing and fencing. Moreover, people with hydrocephalus must have a good emotional balance as it can be overwhelming and cause mental health issues such as depression and anxiety. These can be tackled by going to therapy to talk your emotions aloud and by healthy eating.²¹ It is also important to avoid high-stress driving situations and to limit driving according to how severe the symptoms are.  

Alternative transportation options

People with hydrocephalus may be disappointed that they cannot drive with active symptoms of hydrocephalus, however, they can still go about and live their own independent lives by using public transport. They can use buses, subways and trains as a means of transport. There are also services called paratransit for people who can’t find buses or trains that are available. Paratransit services are a type of public transport that is available to people who are unable to access vans or buses using steps. There are also local community groups and churches that offer social service agencies in the area and will have a lot of volunteers that will help people with transportation. Furthermore, it will also be helpful if they create an Uber account so they can be picked up by and dropped off at their destinations more efficiently.²²

Conclusion

In conclusion, it is important that people with hydrocephalus report their symptoms to DVLA before taking driving lessons as they may be unable to drive since it would be unsafe as hydrocephalus affects a person’s cognitive ability. Therefore important considerations to make are to get scans done to identify the symptoms and make sure certain lifestyle changes are done to control the symptoms.