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Pedersen SH, Prein TH, Ammar A, Grotenhuis A, Hamilton MG, Hansen TS, Kehler U, Rekate H, Thomale UW, Juhler M. How to define CSF overdrainage: a systematic literature review. Acta Neurochir (Wien) 2023; 165:429-441. [PMID: 36639536 DOI: 10.1007/s00701-022-05469-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/20/2022] [Indexed: 01/15/2023]
Abstract
PURPOSE Overdrainage (OD) is one of the most frequent complications related to drainage of the cerebrospinal fluid (CSF). It is mostly associated with valve-bearing shunt systems but should probably be considered as a risk factor in any type of CSF diversion procedure. There is extreme variation in the reported incidence of OD due to the lack of consensus on defining criteria and an unclear perception of the pathophysiology. Hence, OD is probably underreported and underestimated. The objective of this paper was to establish a definition of OD, based on a systematic review of the literature. METHODS A systematic search was conducted in MEDLNE and EMBASE. Studies providing a definition or a description of diagnostic findings related to OD in ventriculoperitoneal shunt treated hydrocephalus were included. Non-English titles, abstracts and manuscripts were excluded. Extracted descriptions were graded into five groups (class I-V studies) based on how precise the terminology used to describe OD was. Class I studies were included for further analysis and characteristics of OD were extracted. The quality of included descriptions was assessed by a clinical expert panel. RESULTS A total of 1309 studies were screened, 190 were graded into groups, and 22, which provided specific definitions or descriptions of OD, were graded as class I studies. We extracted 32 different characteristics consistent with OD (e.g., clinical symptoms, radiological signs, and syndromes). CONCLUSION There was an overall agreement that CSF overdrainage following implantation of a ventriculoperitoneal shunt in a mixed pediatric and adult population is characterized as a persistent condition with clinically manifestations as postural dependent headache, nausea, and vomiting and/or radiological signs of slim ventricles and/or subdural collections.
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Affiliation(s)
| | - Tobias Hannibal Prein
- Centre for Orthopaedic Research and Innovation, Slagelse Hospital, Slagelse, Denmark
| | - Ahmed Ammar
- Department of Neurosurgery, King Fahd University Hospital, Al Khobar, Saudi Arabia
| | | | - Mark G Hamilton
- Department of Clinical Neurosciences, Division of Neurosurgery, University of Calgary, Calgary, Canada
| | | | - Uwe Kehler
- Department of Neurosurgery, Asklepios Klinik Altona, Hamburg, Germany
| | - Harold Rekate
- The Donald and Barbara Zucker Hofstra Northwell School of Medicine, Hempstead, New York, USA
| | | | - Marianne Juhler
- Department of Neurosurgery, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
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Surgical Treatment of Long-Standing Overt Ventriculomegaly in Adults (LOVA): A Comparative Case Series between Ventriculoperitoneal Shunt (VPS) and Endoscopic Third Ventriculostomy (ETV). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19041926. [PMID: 35206112 PMCID: PMC8872207 DOI: 10.3390/ijerph19041926] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/04/2022] [Accepted: 02/06/2022] [Indexed: 02/01/2023]
Abstract
Background: Long-standing overt ventriculomegaly in adults (LOVA) is an uncommon type of adult chronic hydrocephalus. In recent years, conflicting case series described different outcomes after treatment of LOVA with endoscopic third ventriculostomy (ETV) or ventriculoperitoneal shunt (VPS). The aim of this study is to report a single institutional surgical experience of patients with LOVA in order to evaluate the clinical outcome of those patients treated with one or, sometimes, both surgical procedures, analyzing the main clinical features of these patients, before and after surgery. Methods: We conducted a retrospective study on 31 patients with diagnosis of LOVA, who were treated in our University Hospital between December 2010 and October 2020. We reported gender, age, clinical presentation, surgical treatment, and clinical outcome according to the Kiefer index (KI). Evans’ index, head circumference, aqueductal stenosis and expanded/destroyed sella turcica were assessed on preoperative MRI. Results: The most common clinical manifestation was gait disturbances (100%) followed by urinary incontinence in 23 (74.2%) patients and cognitive deficits in 22 (71%) patients. On preoperative MRI, the overall mean Evans’s Index was 0.49, whereas the overall mean head circumference was 57.3 cm. Twenty-three patients (74.2%) had obliterated cortical sulci, 20 (64.5%) patients had aqueductal stenosis, and 22 (71%) patients had an expanded/destroyed sella turcica on preoperative MRI. Fifteen (48.4%) patients underwent ETV and sixteen (51.6%) were treated with VPS as first surgical procedure. Four (26.6%) out of fifteen patients treated with ETV required a subsequent VPS. The overall median age of patients was 64 (IQR: 54.5–74) and the overall median follow-up was 57 months (IQR 21.5–81.5). Overall morbidity was 22.5%. Mean recovery index (RI), according to KI, was 3.8 ± 4.3 and 2.2 ± 5.6 (p = 0.05) at last follow-up in patients treated with ETV and VPS, respectively. Conclusions: The choice of surgical treatment of LOVA remains under discussion. Although EVT is a tempting option for patients with LOVA, conversion to VP shunt is not uncommon.
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Arts S, van Lieshout JH, van Bilsen M, Karadag C, Beez T, van den Abbeele L, Aquarius R, Vinke S, Bartels RHMA, van Lindert EJ, Hänggi D, Boogaarts HD. Non-adjustable gravitational valves or adjustable valves in the treatment of hydrocephalus after aneurysmal subarachnoid hemorrhage patients? Acta Neurochir (Wien) 2022; 164:2867-2873. [PMID: 36149501 PMCID: PMC9613573 DOI: 10.1007/s00701-022-05361-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 09/03/2022] [Indexed: 01/31/2023]
Abstract
PURPOSE Hydrocephalus requiring permanent CSF shunting after aneurysmal subarachnoid hemorrhage (aSAH) is frequent. It is unknown which type of valve is optimal. This study evaluates if the revision rate of gravitational differential pressure valves (G-DPVs, GAV® system (B Braun)) (G-DPV) is comparable to adjustable pressure valves (Codman Medos Hakim) (APV) in the treatment of post-aSAH hydrocephalus. METHODS The use of a gravitational differential pressure valve is placed in direct comparison with an adjustable pressure valve system. A retrospective chart review is performed to compare the revision rates for the two valve systems. RESULTS Within the registry from Radboud University Medical Center, 641 patients with a SAH could be identified from 1 January 2013 until 1 January 2019, whereas at the Heinrich Heine University, 617 patients were identified, totaling 1258 patients who suffered from aSAH. At Radboud University Medical Center, a gravitational differential pressure valve is used, whereas at the Heinrich Heine University, an adjustable pressure valve system is used. One hundred sixty-six (13%) patients required permanent ventricular peritoneal or atrial shunting. Shunt dysfunction occurred in 36 patients: 13 patients of the 53 (25%) of the gravitational shunt cohort, and in 23 of the 113 (20%) patients with an adjustable shunt (p = 0.54). Revision was performed at a mean time of 3.2 months after implantation with the gravitational system and 8.2 months with the adjustable shunt system. Combined rates of over- and underdrainage leading to revision were 7.5% (4/53) for the gravitational and 3.5% (4/113) for the adjustable valve system (p = 0 .27). CONCLUSION The current study does not show a benefit of a gravitational pressure valve (GAV® system) over an adjustable pressure valve (CODMAN ® HAKIM®) in the treatment of post-aSAH hydrocephalus. The overall need for revision is high and warrants further improvements in care.
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Affiliation(s)
- Sebastian Arts
- grid.10417.330000 0004 0444 9382Department of Radiology, Radboud University Medical Center, Nijmegen, The Netherlands ,grid.10417.330000 0004 0444 9382Department of Neurosurgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Jasper Hans van Lieshout
- grid.411327.20000 0001 2176 9917Department of Neurosurgery, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Martine van Bilsen
- grid.10417.330000 0004 0444 9382Department of Neurosurgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Cihat Karadag
- grid.411327.20000 0001 2176 9917Department of Neurosurgery, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Thomas Beez
- grid.411327.20000 0001 2176 9917Department of Neurosurgery, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Leonie van den Abbeele
- grid.10417.330000 0004 0444 9382Department of Neurosurgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Rene Aquarius
- grid.10417.330000 0004 0444 9382Department of Neurosurgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Saman Vinke
- grid.10417.330000 0004 0444 9382Department of Neurosurgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Ronald H. M. A. Bartels
- grid.10417.330000 0004 0444 9382Department of Neurosurgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Erik J. van Lindert
- grid.10417.330000 0004 0444 9382Department of Neurosurgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Daniel Hänggi
- grid.411327.20000 0001 2176 9917Department of Neurosurgery, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Hieronymus D. Boogaarts
- grid.10417.330000 0004 0444 9382Department of Neurosurgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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Udayakumaran S, Pattisapu J. Controversies in Hydrocephalus: QUO VADIS. Neurol India 2021; 69:S575-S582. [DOI: 10.4103/0028-3886.332269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Gutowski P, Gölz L, Rot S, Lemcke J, Thomale UW. Gravitational shunt valves in hydrocephalus to challenge the sequelae of over-drainage. Expert Rev Med Devices 2020; 17:1155-1168. [PMID: 33176494 DOI: 10.1080/17434440.2020.1837622] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION In hydrocephalus treatment, ventriculo-peritoneal shunts (VPS) have become the most relevant therapy for seven decades among other treatment options. Due to the hydrostatic pressure in vertical position, CSF diversion is somehow non-physiological. The integration of gravitational valves in VPS was established to counteract the hydrostatic draining force and to approach a physiological condition of the cerebrospinal diverting system. Numerous clinical studies have shown that gravitational valves are able to reduce secondary complications of VPS treatment. It remains a challenge for the treating neurosurgeon to select the correct valve resistance based on individual anatomies and different etiologies of hydrocephalus as well as varying levels of activity of the patient. AREAS COVERED This review covers the development of gravitational shunt valves from historical, theoretical and clinical aspects for pediatric and adult etiologies of hydrocephalus. We discuss the role of gravitational shunt valves in preventing over-drainage issues and present the state-of-the-art literature. Furthermore, ongoing prospective trials are presented. EXPERT OPINION Counteracting the hydrostatic force by selecting the correct valve in a VPS system to achieve physiological balance in CSF diversion during vertical and horizontal body changes has become the current standard for hydrocephalus management. Gravitational shunt valves reliably address this need to minimize over-drainage events in the vertical position without affecting the CSF flow in the horizontal position. The results of ongoing prospective studies on the safety and efficacy of adjustable gravitational valves are still pending. Due to the complexity of the CSF flow, lifelong follow-up care for patients with VPS is critical.
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Affiliation(s)
- Paweł Gutowski
- Department of Neurosurgery, Unfallkrankenhaus Berlin , Berlin, Germany.,Department of Neurosurgery, Bródno Mazovia Hospital , Warsaw, Poland
| | - Leonie Gölz
- Institute of Radiology and Neuroradiology, Unfallkrankenhaus , Berlin, Germany
| | - Sergej Rot
- Department of Neurosurgery, Unfallkrankenhaus Berlin , Berlin, Germany
| | - Johannes Lemcke
- Department of Neurosurgery, Unfallkrankenhaus Berlin , Berlin, Germany
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Fiss I, Röhrig P, Hore N, von der Brelie C, Bettag C, Freimann FB, Thomale UW, Rohde V, Brandner S. In vitro performance of six combinations of adjustable differential pressure valves and fixed anti-siphon devices with and without vertical motion. Acta Neurochir (Wien) 2020; 162:2421-2430. [PMID: 32779025 DOI: 10.1007/s00701-020-04519-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 07/30/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Adjustable differential pressure (DP) valves in combination with fixed anti-siphon devices are currently a popular combination in counteracting the effects of cerebrospinal fluid overdrainage following implantation of a ventriculoperitoneal shunt system. The study examined the flow performance of three DP valves in successive combination with an anti-siphon device in an in vitro shunt laboratory with and without vertical motion. METHODS We analyzed three DP valves (Codman Hakim Medos programmable valve [HM], Codman CertasPlus [CP], and Miethke proGAV [PG], in combination with either Codman SiphonGuard [SG] or Miethke ShuntAssistant [SA]), resulting in the evaluation of six different valve combinations. Defined DP conditions between 4 and 40 cm H2O within a simulated shunt system were generated and the specific flow characteristics were measured. In addition, combinations with SA, which is a gravity-dependent valve, were measured in defined spatial positions (90°, 60°). All device combinations were tested during vertical motion with movement frequencies of 2, 3, and 4 Hz. RESULTS All valve combinations effectively counteracted the siphon effect in relation to the chosen DP. Angulation-related flow changes were similar in the three combinations of DP valve and SA in the 60° and 90° position. In CP-SA and PG-SA, repeated vertical movement at 2, 3, and 4 Hz led to significant increase in flow, whereas in HM-SA, constant increase was seen at 4 Hz only (flow change at 4Hz, DP 40 cm H2O: PG (opening pressure 4 cm H2O) 90°: 0.95 ml/min, 60°: 0.71 ml/min; HM (opening pressure 4 cm H2O) 90°: 0.66 ml/min, 60°: 0.41 ml/min; CP (PL 2) 90°: 0.94 ml/min, 60°: 0.79 ml/min; p < 0.01); however, HM-SA showed relevant motion-induced flow already at low DPs (0.85 ml/min, DP 4 cm H2O). In combinations of DP valve with SG, increase of flow was far less pronounced and even led to significant reduction of flow in certain constellations. Maximum overall flow increase was 0.46 ± 0.04 ml/min with a HM (opening pressure 12 cm H2O) at 2 Hz and a DP of 10 cm H2O, whereas maximum flow decrease was 1.12 ± 0.08 with a PG (opening pressure 4 cm H2O) at 3 Hz and a DP of 10 cmH2O. CONCLUSION In an experimental setup, all valve combinations effectively counteracted the siphon effect in the vertical position according to their added resistance. Motion-induced increased flow was consistently demonstrated in combinations of DP valve and SA. The combination of HM and SA especially showed relevant motion-induced flow already at low DPs. In combinations of DP and SG, the pattern of the motion induced flow was more inconsistent and motion even led to significant flow reduction, predominantly at DPs of 10 and 20 cmH2O.
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Affiliation(s)
- I Fiss
- Department of Neurosurgery, University Hospital Göttingen, Göttingen, Germany.
- Department of Neurosurgery, Universitätsmedizin Göttingen, Georg-August University Göttingen, 37099, Göttingen, Germany.
| | - P Röhrig
- Department of Neurosurgery, University Hospital Göttingen, Göttingen, Germany
| | - N Hore
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany
| | - C von der Brelie
- Department of Neurosurgery, University Hospital Göttingen, Göttingen, Germany
| | - C Bettag
- Department of Neurosurgery, University Hospital Göttingen, Göttingen, Germany
| | - F B Freimann
- Department of Neurosurgery, University Hospital Göttingen, Göttingen, Germany
| | - U-W Thomale
- Department of Paediatric Neurosurgery, Charité University Hospital, Berlin, Germany
| | - V Rohde
- Department of Neurosurgery, University Hospital Göttingen, Göttingen, Germany
| | - S Brandner
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany
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Desai VR, Sadrameli SS, Jenson AV, Asante SK, Daniels B, Trask TW, Britz G. Ventriculoperitoneal shunt complications in an adult population: A comparison of various shunt designs to prevent overdrainage. Surg Neurol Int 2020; 11:269. [PMID: 33033631 PMCID: PMC7538957 DOI: 10.25259/sni_38_2020] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 06/09/2020] [Indexed: 11/10/2022] Open
Abstract
Background: Overdrainage after cerebrospinal fluid diversion remains a significant morbidity. The hydrostatic, gravitational force in the upright position can aggravate this. Siphon control (SC) mechanisms, as well as programmable and flow regulating devices, were developed to counteract this. However, limited studies have evaluated their safety and efficacy. In this study, direct comparisons of the complication rates between siphon control (SC) and non-SC (NSC), fixed versus programmable, and flow- versus pressure regulating valves are undertaken. Methods: A retrospective chart review was performed over all shunt implantations from January 2011 to December 2016 within the Houston Methodist Hospital system. Complication rates within 6 months of the operative date, including infection, subdural hematoma, malfunction, and any other shunt-related complication, were analyzed via Fisher’s exact test, with P < 0.05 regarded as significant. Subgroup analyses based on diagnoses – normal pressure hydrocephalus (HCP), pseudotumor cerebri, or other HCP – were also performed. Results: The overall shunt-related complication rate in this study was 19%. Overall rates of infection, shunt failure, and readmission within 180 days were 3%, 11%, and 34%, respectively. No difference was seen between SC and NSC groups in any complication rate overall or on subgroup analyses. When comparing fixed versus programmable and flow- versus pressure-regulating valves, the latter in each analysis had significantly lower malfunction and total complication rates. Conclusions: Programmable and pressure regulating devices may lead to lower shunt malfunction and total complication rates. Proper patient selection should guide valve choice. Future prospective studies may further elucidate the difference in complication rates between these various shunt designs.
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Affiliation(s)
- Virendra Rajendrakumar Desai
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, United States
| | - Saeed Sam Sadrameli
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, United States
| | - Amanda V Jenson
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, United States
| | - Samuel K Asante
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, United States
| | - Bradley Daniels
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, United States
| | - Todd W Trask
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, United States
| | - Gavin Britz
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston Methodist Hospital, Houston, Texas, United States
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Fiss I, Vanderheyden M, von der Brelie C, Bettag C, Hore N, Freimann F, Thomale UW, Rohde V, Brandner S. In vitro performance of combinations of anti-siphon devices with differential pressure valves in relation to the spatial position. Acta Neurochir (Wien) 2020; 162:1033-1040. [PMID: 31997071 DOI: 10.1007/s00701-020-04228-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/13/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Programmable differential pressure (DP) valves combined with an anti-siphon device (ASD) represent the current standard of care in preemtping overdrainage associated with ventriculoperitoneal shunting for hydrocephalus. OBJECTIVE We aimed to provide comparative data of four combinations of two ASDs of different working principles in combination with two DP valves in an in vitro model in order to achieve a better understanding of the flow characteristics and potential clinical application. METHODS We analyzed the flow performance of four possible combinations of two DP valves (CHPV [HM]; proGAV 2.0[PG]) in combination with either a gravity-regulated (Shuntassistant [SA]) or a flow-regulated (SiphonGuard [SG]) ASD in an in vitro setup. A DP between 4 and 60 cmH2O was generated, and the specific flow characteristics were measured. In addition, the two combinations with gravity-regulated ASDs were measured in defined spatial positions. RESULTS Flow characteristics of the SA combinations corresponded to the DP in linear fashion and to the spatial position. Flow characteristics of the SG combinations were dependent upon the DP in a non-linear fashion and independent of the spatial position. Highest mean flow rate of the PG-SG- (HM-SG-) combination was 1.41 ± 0.24 ml/min (1.16 ± 0.06 ml/min). The mean flow rates sharply decreased with increasing inflow pressure and subsequently increased slowly up to 0.82 ± 0.26 ml/min (0.77 ± 0.08 ml/min). CONCLUSION All tested device combinations were able to control hydrostatic effect and prevent consecutive excessive flow, to varying degrees. However, significant differences in flow characteristics can be seen, which might be relevant for their clinical application.
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Affiliation(s)
- I Fiss
- Department of Neurosurgery, Universitätsmedizin Göttingen, Georg-August University Göttingen, 37099, Göttingen, Germany.
| | - M Vanderheyden
- Department of Neurosurgery, Universitätsmedizin Göttingen, Georg-August University Göttingen, 37099, Göttingen, Germany
| | - C von der Brelie
- Department of Neurosurgery, Universitätsmedizin Göttingen, Georg-August University Göttingen, 37099, Göttingen, Germany
| | - C Bettag
- Department of Neurosurgery, Universitätsmedizin Göttingen, Georg-August University Göttingen, 37099, Göttingen, Germany
| | - N Hore
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany
| | - F Freimann
- Department of Neurosurgery, Universitätsmedizin Göttingen, Georg-August University Göttingen, 37099, Göttingen, Germany
| | - U-W Thomale
- Department of Paediatric Neurosurgery, Charité University Hospital, Berlin, Germany
| | - V Rohde
- Department of Neurosurgery, Universitätsmedizin Göttingen, Georg-August University Göttingen, 37099, Göttingen, Germany
| | - S Brandner
- Department of Neurosurgery, University Hospital Erlangen, Erlangen, Germany
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Davis A, Yasar S, Emerman I, Gulyani S, Khingelova K, Rao A, Manthripragada L, Luciano M, Moghekar A. Standardized regression-based clinical change score cutoffs for normal pressure hydrocephalus. BMC Neurol 2020; 20:140. [PMID: 32299370 PMCID: PMC7164303 DOI: 10.1186/s12883-020-01719-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 04/07/2020] [Indexed: 11/25/2022] Open
Abstract
Background Presently, for patients presenting with suspected Normal Pressure Hydrocephalus (NPH) who undergo temporary drainage of cerebrospinal fluid (CSF) there is no defined model to differentiate chance improvement form clinical significance change at the individual patient level. To address this lack of information we computed standard regression based clinical change models for the 10 Meter Walk Test, Timed Up & Go, Dual Timed Up & Go, 6-Minute Walk Test, Mini-Balance Evaluation Systems Test, Montreal Cognitive Assessment, and Symbol Digit Modalities using data from patients with suspected NPH that underwent temporary drainage of CSF. These clinically significant change modes can classify clinically significant improvement following temporary drainage of CSF at the individual patient level. This allows for physicians to differentiate a clinically significant improvement in symptoms from chance improvement. Methods Data was collected from 323 patients, over the age of 60, with suspected NPH that underwent temporary drainage of CSF with corresponding gait and cognitive testing. McSweeney Standardized Regression Based Clinical Change Models were computed for standard gait and cognitive measures: Timed Up & Go, Dual Timed Up & Go, 10 Meter Walk Test, MiniBESTest, 6-Minute Walk Test, Montreal Cognitive Assessment, and Symbol Digit Modalities Test. To assess the discriminate validity of the measures we used correlations, Chi2, and regression analyses. Results The clinical change models explained 69–91.8% of the variability in post-drain performance (p < 0.001). As patient scores became more impaired, the percent change required for improvement to be clinically significant increased for all measures. We found that the measures were not discriminate, the Timed Up & Go was highly related to the 10 Meter Walk Test (r = 0.85, R2 = 0.769–0.738, p < 0.001), MiniBESTest (r = − 0.67, R2 = 0.589–0.734, p < 0.001), and 6 Minute Walk Test (r = − 0.77, R2 = 0.71–0.734, p < 0.001). Conclusion Standardized Regression Based Clinically Significant Change Models allow for physicians to use an evidence-based approach to differentiate clinically significant change from chance improvement at the individual patient level. The Timed Up & Go was shown to be predictive of detailed measures of gait velocity, balance, and endurance.
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Affiliation(s)
- Alexander Davis
- Department of Neurology, Johns Hopkins University School of Medicine, 5200 Eastern Ave CTR STE 5100, Baltimore, MD, 21224, USA.
| | - Sevil Yasar
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Iris Emerman
- Department of Neurology, Johns Hopkins University School of Medicine, 5200 Eastern Ave CTR STE 5100, Baltimore, MD, 21224, USA
| | - Seema Gulyani
- Department of Neurology, Johns Hopkins University School of Medicine, 5200 Eastern Ave CTR STE 5100, Baltimore, MD, 21224, USA
| | - Kristina Khingelova
- Department of Neurology, Johns Hopkins University School of Medicine, 5200 Eastern Ave CTR STE 5100, Baltimore, MD, 21224, USA
| | - Aruna Rao
- Department of Neurology, Johns Hopkins University School of Medicine, 5200 Eastern Ave CTR STE 5100, Baltimore, MD, 21224, USA
| | | | - Mark Luciano
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | - Abhay Moghekar
- Department of Neurology, Johns Hopkins University School of Medicine, 5200 Eastern Ave CTR STE 5100, Baltimore, MD, 21224, USA
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10
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Scholz R, Lemcke J, Meier U, Stengel D. Efficacy and safety of programmable compared with fixed anti-siphon devices for treating idiopathic normal-pressure hydrocephalus (iNPH) in adults - SYGRAVA: study protocol for a randomized trial. Trials 2018; 19:566. [PMID: 30333067 PMCID: PMC6192316 DOI: 10.1186/s13063-018-2951-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 09/28/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Idiopathic normal-pressure hydrocephalus (iNPH) is a distinct form of dementia, characterized by gait ataxia, cognitive impairment and urinary incontinence. In contrast to all other causes of dementia (e.g., Alzheimer-type and others), ventriculoperitoneal (VP) shunt surgery may offer a curative treatment option to patients. While being a rather low-risk type of surgery, it may cause significant over- or underdrainage complications (e.g., headaches, dizziness, vomiting, intracerebral bleeding, etc.) during posture change. Anti-siphon devices (ASDs) are a group of technically different additional valves used in shunt surgery. They are designed to maintain intraventricular pressure within a normal physiological range regardless of patient position. Fixed ASDs proved to substantially lower the rate of overdrainage complications. No significant differences, however, were noted regarding underdrainage complications. Technical successors of fixed ASDs are programmable ASDs. The aim of this study is to evaluate whether programmable ASDs compared to fixed ASDs are able to avoid both over- and underdrainage complications. METHODS/DESIGN In this investigator-initiated, multicenter randomized trial, 306 patients are planned to be recruited. Male and female patients aged ≥18 years with iNPH who are eligible for VP shunt surgery and meet all other entry criteria can participate. Patients will be randomized in a balanced 1: 1 fashion to a VP shunt with a programmable valve either supplemented with a fixed ASD, or a programmable ASD. Patients will be followed-up 3, 6 and, on an optional basis, 12 months after surgery. The primary outcome measure is the cumulative incidence of over- or underdrainage 6 months post surgery, as defined by clinical and imaging parameters. DISCUSSION SYGRAVA is the first randomized trial to determine whether programmable ASDs reduce complications of drainage compared to fixed ASDs in patients with iNPH. The results of this study may contribute to health-technology assessment of different valve systems used for VP-shunt surgery, and determination of the future standard of care. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number: ISRCTN13838310 . Registered on 10 November 2016.
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Affiliation(s)
- Romy Scholz
- Centre for Clinical Research, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Johannes Lemcke
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany.
| | - Ullrich Meier
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany
| | - Dirk Stengel
- Centre for Clinical Research, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany.,Department of Trauma and Orthopaedic Surgery, Unfallkrankenhaus Berlin, Warener Str. 7, 12683, Berlin, Germany.,Julius Wolff Institute, Charité Medical University Centre, Augustenburger Platz 1, 13353, Berlin, Germany
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The applicability of fixed and adjustable gravitational shunt valves in two different clinical settings. Acta Neurochir (Wien) 2018; 160:1415-1423. [PMID: 29804178 DOI: 10.1007/s00701-018-3568-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 05/16/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Gravitational shunt valves and most recently the adjustable proSA® gravitational valve have been designed to counteract overdrainage and thereby improving clinical outcome. So far, the applicability in a broader mix of hydrocephalus patients is unrevealed. The aim of this study was to evaluate the utility of gravitational valves in two different clinical settings. METHODS This retrospective double-center cohort study was enabled by two different shunt management policies. At Rigshospitalet, patients with a complicated shunt history receiving a proGAV® and proSA® shunt system during surgical revision were included, and clinical outcome in the follow-up periods before and after was compared. At Aarhus University Hospital, a combination of a proGAV® and a fixed (SA®) or adjustable (proSA®) gravitational valve was used in all shunt procedures. Clinical outcome in a 2-year follow-up period was compared to a cohort receiving non-gravitational valves in the period before the transition to gravitational valves. RESULTS Twenty-two patients were included at Rigshospitalet. Mean follow-up time before and after proGAV® and proSA® implantation was 2.3 and 1.5 years, respectively. In each patient, roughly two surgical revisions (p 0.031) and two hospitalizations (p 0.009) were avoided each year after proGAV® and proSA® implantation. At Aarhus University Hospital, 90 patients with non-gravitational valves and 98 patients with gravitational valves were included. Changes in clinical outcome parameters and shunt survivals were either stable or statistically insignificant. CONCLUSIONS Gravitational valves are safe and useful in clinical practice and represent an equivalent alternative as a first-line shunt valve in a broad mix of patients, while proSA® valves should be considered for complex shunt patients.
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Antes S, Stadie A, Müller S, Linsler S, Breuskin D, Oertel J. Intracranial Pressure–Guided Shunt Valve Adjustments with the Miethke Sensor Reservoir. World Neurosurg 2018; 109:e642-e650. [DOI: 10.1016/j.wneu.2017.10.044] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 10/08/2017] [Accepted: 10/10/2017] [Indexed: 01/08/2023]
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Virhammar J, Laurell K, Cesarini KG, Larsson EM. Increase in callosal angle and decrease in ventricular volume after shunt surgery in patients with idiopathic normal pressure hydrocephalus. J Neurosurg 2018; 130:130-135. [DOI: 10.3171/2017.8.jns17547] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 08/01/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEPostoperative decrease in ventricle size is usually not detectable either by visual assessment or by measuring the Evans index in patients with idiopathic normal pressure hydrocephalus (iNPH). The aim of the present study was to investigate whether the angle between the lateral ventricles (the callosal angle [CA]) increases and ventricular volume decreases after shunt surgery in patients with iNPH.METHODSMagnetic resonance imaging of the brain was performed before and 3 months after shunt surgery in 18 patients with iNPH. The CA and Evans index were measured on T1-weighted 3D MR images, and ventricular volume contralateral to the shunt valve was measured with quantitative MRI.RESULTSThe CA was larger postoperatively (mean 78°, 95% CI 69°–87°) than preoperatively (mean 67°, 95% CI 60°–73°; p < 0.001). The volume of the lateral ventricle contralateral to the shunt valve decreased from 73 ml (95% CI 66–80 ml) preoperatively to 63 ml (95% CI 54–72 ml) postoperatively (p < 0.001). The Evans index was 0.365 (95% CI 0.35–0.38) preoperatively and 0.358 (95% CI 0.34–0.38) postoperatively (p < 0.05). Postoperative change of CA showed a negative correlation with change of ventricular volume (r = −0.76, p < 0.01).CONCLUSIONSIn this sample of patients with iNPH, the CA increased and ventricular volume decreased after shunt surgery. The relative difference was most pronounced for the CA, indicating that this accessible, noninvasive radiological marker should be evaluated further as an indirect method to determine shunt function in patients with iNPH.
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Affiliation(s)
| | - Katarina Laurell
- 2Department of Pharmacology and Clinical Neuroscience, Unit of Neurology, Umeå University, Umeå, Sweden
| | | | - Elna-Marie Larsson
- 4Department of Surgical Sciences, Radiology, Uppsala University, Uppsala; and
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Kaestner S, Poetschke M, Roth C, Deinsberger W. Different origins of hydrocephalus lead to different shunt revision rates. Neurol Neurochir Pol 2017; 51:72-76. [PMID: 28063609 DOI: 10.1016/j.pjnns.2016.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 08/20/2016] [Accepted: 11/20/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Hydrocephalus (HC) occurs due to multiple origins. Time course and dynamic of HC and its therapies differ between underlying pathologies. Different revision rates due to the type of HC are expected. Though hydrocephalus is known to be a life time condition, the lack of shunt malfunction years or decades after initial shunt insertion raises the hope of a superfluous shunt. METHODS We conducted a retrospective survey of our OR-database during a 10 year period. All newly inserted shunt systems and subsequent shunt revisions are recorded according to quantity and time point. All patients were subdivided according their aetiology of HC. RESULTS 260 patients were eligible with a follow-up of 4.5 years. Subgroups were: 90 patients with NPH, 76 patients with posthaemorrhagic and 16 patients had posttraumatic HC. 22 received a shunt as a consequence of a tumour, 41 were children and 15 for other causes. Overall revision rate was 39.5%. During the first 6 months 55.6%, 57.9% and 75% of patients with NPH, posthaemorrhagic and posttraumatic HC had revisions. In contrast only 38.1% of children and 20% of tumour cases required early revision. CONCLUSION Two different patterns of revision are evident: mainly early revisions in morphologically stable diseases such as posthaemorrhagic, posttraumatic and NPH and predominantly late revisions in changing organisms such as children and tumour patients. The conception HC may be transient because of a lack of late revisions cannot be supported by this data.
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Affiliation(s)
| | - Manuela Poetschke
- Applied Statistics, Department 05, University of Kassel, Kassel, Germany
| | - Christian Roth
- Department of Neurology, Klinikum Kassel, Kassel, Germany
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In vitro performance of the fixed and adjustable gravity-assisted unit with and without motion-evidence of motion-induced flow. Acta Neurochir (Wien) 2016; 158:2011-8. [PMID: 27553048 DOI: 10.1007/s00701-016-2912-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 07/27/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Anti-siphon devices and gravitational-assisted valves have been introduced to counteract the effects of overdrainage after implantation of a shunt system. The study examined the flow performance of two gravitational-assisted valves (shunt assistant - SA and programmable shunt assistant - proSA, Miethke & Co. KG, Potsdam, Germany) in an in vitro shunt laboratory with and without motion. METHODS An in vitro laboratory setup was used to model the cerebrospinal fluid (CSF) drainage conditions similar to a ventriculo-peritoneal shunt and to test the SA (resistance of +20 cmH2O in 90°) and proSA (adjustable resistance of 0 to +40 cmH2O in 90°). The differential pressure (DP) through the simulated shunt and tested valve was adjusted between 0 and 60 cmH2O by combinations of different inflow pressures (40, 30, 20, 10, and 0 cmH2O) and the hydrostatic negative outflow pressure (0, -20, and -40 cmH2O) in several differing device positions (0°, 30°, 60°, and 90°). In addition, the two devices were tested under vertical motion with movement frequencies of 2, 3, and 4 Hz. RESULTS Both gravity-assisted units effectively counteract the hydrostatic effect in relation to the chosen differential pressure. The setting the proSA resulted in flow reductions in the 90° position according to the chosen resistance of the device. Angulation-related flow changes were similar in the two devices in 30-90° position, however, in the 0-30° position, a higher flow is seen in the proSA. Repeated vertical movement significantly increased flow through both devices. While with the proSA a 2-Hz motion was not able to induce additional flow (0.006 ± 0.05 ml/min), 3- and 4-Hz motion significantly induced higher flow values (3 Hz: +0.56 ± 0.12 ml/min, 4 Hz: +0.54 ± 0.04 ml/min). The flow through the SA was not induced by vertical movements at a low DP of 10 cmH2O at all frequencies, but at DPs of 30 cmH2O and higher, all frequencies significantly induced higher flow values (2 Hz: +0.36 ± 0.14 ml/min, 3 Hz: +0.32 ± 0.08 ml/min, 4 Hz: +0.28 ± 0.09 ml/min). CONCLUSIONS In a static setup, both tested valves effectively counteracted the hydrostatic effect according to their adjusted or predefined resistance in vertical position. Motion-induced increased flow was demonstrated for both devices with different patterns of flow depending on applied DP and setting of the respective valve. The documented increased drainage should be considered when selecting appropriate valves and settings in very active patients.
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Antes S, Tschan CA, Heckelmann M, Breuskin D, Oertel J. Telemetric Intracranial Pressure Monitoring with the Raumedic Neurovent P-tel. World Neurosurg 2016; 91:133-48. [DOI: 10.1016/j.wneu.2016.03.096] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2016] [Revised: 03/28/2016] [Accepted: 03/29/2016] [Indexed: 01/19/2023]
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Suchorska B, Kunz M, Schniepp R, Jahn K, Goetz C, Tonn JC, Peraud A. Optimized surgical treatment for normal pressure hydrocephalus: comparison between gravitational and differential pressure valves. Acta Neurochir (Wien) 2015; 157:703-9. [PMID: 25666108 DOI: 10.1007/s00701-015-2345-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 01/05/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVES In idiopathic normal pressure hydrocephalus (NPH) ventriculoperitoneal (VP) shunt insertion is the method of choice to improve cardinal symptoms such as gait disturbance, urge incontinence and/or dementia. With reduced compliance, the brain of the elderly is prone for overdrainage complications. This was especially true with the use of differential pressure valve implantation. The present study compares clinical outcome and complication rates after VP shunt insertion with differential pressure valves in the early years and gravitational valves since 2005. METHODS The authors reviewed patients treated at our institution for NPH since 1995. Differential pressure valves were solely used in the initial years, while the treatment regimen changed to gravitational valves in 2005. Clinical improvement/surgical success rates as well as complications were compared between the two groups. RESULTS Eighty-nine patients were enrolled for the present study. Mean age at the time of surgery was 73.5 ± 6.3 years. Male patients predominated with 73, compared with 16 female patients. Median follow-up time was 28 ± 26 months. Date of last follow-up was 1st October 2013. Forty-nine patients received a gravitational valve, while 40 were treated with differential pressure valves. In the gravitational group a significant improvement was observed after shunt insertion for gait disorder, cognitive impairment and urge incontinence (p < 0.0001, resp. p = 0.004), while a significant change in the differential pressure group was only seen for gait disorder (p = 0.03) but not for cognition or urinary incontinency (p > 0.05). The risk of hygroma as a sign of shunt overdrainage requiring surgical intervention was significantly higher in the differential pressure group (5 versus 0 in the gravitational group). CONCLUSIONS Patients with NPH treated with gravitational valves in the present cohort showed a more profound improvement in their initial symptoms, including gait disorder, cognitive impairment and urinary incontinency without the risk of overdrainage complications requiring surgical intervention when compared with patients who received differential pressure valves in previous years.
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Affiliation(s)
- B Suchorska
- Klinikum Großhadern, Neurochirurgische Klinik und Poliklinik, Marchioninistrasse 15, 81377, München, Germany
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In vitro performance and principles of anti-siphoning devices. Acta Neurochir (Wien) 2014; 156:2191-9. [PMID: 25123252 DOI: 10.1007/s00701-014-2201-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 08/05/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Anti-siphon devices (ASDs) of various working principles were developed to overcome overdrainage-related complications associated with ventriculoperitoneal shunting. OBJECTIVE We aimed to provide comparative data on the pressure and flow characteristics of six different types of ASDs (gravity-assisted, membrane-controlled, and flow-regulated) in order to achieve a better understanding of these devices and their potential clinical application. METHODS We analyzed three gravity-dependent ASDs (ShuntAssistant [SA], Miethke; Gravity Compensating Accessory [GCA], Integra; SiphonX [SX], Sophysa), two membrane-controlled ASDs (Anti-Siphon Device [IASD], Integra; Delta Chamber [DC], Medtronic), and one flow-regulated ASD (SiphonGuard [SG], Codman). Defined pressure conditions within a simulated shunt system were generated (differential pressure 10-80 cmH2O), and the specific flow and pressure characteristics were measured. In addition, the gravity-dependent ASDs were measured in defined spatial positions (0-90°). RESULTS The flow characteristics of the three gravity-assisted ASDs were largely dependent upon differential pressure and on their spatial position. All three devices were able to reduce the siphoning effect, but each to a different extent (flow at inflow pressure: 10 cmH2O, siphoning -20 cmH2O at 0°/90°: SA, 7.1 ± 1.2*/2.3 ± 0.5* ml/min; GCA, 10.5 ± 0.8/3.4 ± 0.4* ml/min; SX, 9.5 ± 1.2*/4.7 ± 1.9* ml/min, compared to control, 11.1 ± 0.4 ml/min [*p < 0.05]). The flow characteristics of the remaining ASDs were primarily dependent upon the inflow pressure effect (flow at 10 cmH2O, siphoning 0 cmH2O/ siphoning -20cmH2O: DC, 2.6 ± 0.1/ 4 ± 0.3* ml/min; IASD, 2.5 ± 0.2/ 0.8 ± 0.4* ml/min; SG, 0.8 ± 0.2*/ 0.2 ± 0.1* ml/min [*p < 0.05 vs. control, respectively]). CONCLUSION The tested ASDs were able to control the siphoning effect within a simulated shunt system to differing degrees. Future comparative trials are needed to determine the type of device that is superior for clinical application.
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Gölz L, Ruppert FH, Meier U, Lemcke J. Outcome of modern shunt therapy in patients with idiopathic normal pressure hydrocephalus 6 years postoperatively. J Neurosurg 2014; 121:771-5. [DOI: 10.3171/2014.6.jns131211] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Shunt therapy in idiopathic normal pressure hydrocephalus (iNPH) can improve symptoms in 84% of patients 1 year postoperatively. Therefore, implantation of a ventriculoperitoneal shunt (VPS) prevents or at least prolongs the time during which patients are not dependent on care from others because of gait disorder or dementia. In this study, the medium-term results of modern shunt therapy were evaluated.
Methods
The authors retrospectively studied outcome in iNPH patients in whom VPSs were implanted. At yearly follow-up examinations over at least 6 years, clinical symptoms were recorded according to the NPH recovery rate (NPH-RR): (preoperative Kiefer Scale [KS] score − postoperative KS score)/(preoperative KS score × 10). Time and cause of death over this period were also analyzed.
Results
Among the 147 patients treated for iNPH in the period between 1997 and 2006, 69 had died at the time of the authors' survey. Sixty-one patients reached the 6-year examination. The median age was 64 years (range 33–83 years) at the time of VPS implantation and 73 years (range 41–91 years) at the time of this study. Six years after shunt implantation, the median KS score was significantly lower than the preoperative score (4.3 vs 8.1 points). Fifty-nine percent of 61 patients had an excellent outcome, 15% had satisfactory benefit, and 26% had unsatisfactory results 6 years postoperatively. Three of the 147 patients who underwent implantation of a VPS died of cerebral diseases 4–10 years postoperatively.
Conclusions
Implantation of a VPS is a safe procedure and can improve symptoms in 74% of patients with iNPH in the longer term.
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Freimann FB, Luhdo ML, Rohde V, Vajkoczy P, Wolf S, Sprung C. The Frankfurt horizontal plane as a reference for the implantation of gravitational units: a series of 376 adult patients. Acta Neurochir (Wien) 2014; 156:1351-6. [PMID: 24792967 DOI: 10.1007/s00701-014-2076-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 03/19/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND The in-line combination of adjustable differential pressure valves with fixed gravitational units is increasingly recommended in the literature. The spatial positioning of the gravitational unit is thereby decisive for the valve opening pressure. We aimed at providing data on factors contributing to primary overdrainage and underdrainage of cerebrospinal fluid (CSF), with special attention paid to the implantation angle of the gravitational unit. METHODS Weretrospectively analyzed the postoperative course of 376 consecutive patients who received a ventriculoperitoneal shunt with a proGAV valve. The incidence of both primary CSF overdrainage and underdrainage was correlated with the implantation angle of the gravitational unit in regard to the Frankfurt horizontal plane and the patients' general parameters. RESULTS Primary overdrainage was found in 41 (10.9 %) patients. Primary underdrainage was found in 113 (30.1 %) patients. A mean deviation of 10° (±7.8) for the gravitational unit in regard to the vertical line to the Frankfurt horizontal plane was found. In 95 % of the cases the deviation was less than 25°. No significant correlation between the implantation angle and the incidence of overdrainage or underdrainage of CSF was found. The patients' age and having single hydrocephalus entities were identified as factors significantly predisposing patients to overdrainage or underdrainage. CONCLUSION The implantation of the gravitational unit of the proGAV valve within a range of at least 10° in regard to the vertical line to the Frankfurt horizontal plane does not seem to predispose patients to primary overdrainage or underdrainage in ventriculoperitoneal shunting. The plane may serve as a useful reference for the surgeon's orientation.
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Tschan CA, Antes S, Huthmann A, Vulcu S, Oertel J, Wagner W. Overcoming CSF overdrainage with the adjustable gravitational valve proSA. Acta Neurochir (Wien) 2014; 156:767-76; discussion 776. [PMID: 24292775 DOI: 10.1007/s00701-013-1934-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 10/31/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite progress in shunt valve technology, CSF overdrainage is still one of the most frequent complications in shunt-treated hydrocephalus. Particularly with regard to young and adolescent patients, treatment of manifest overdrainage is complicated by several hardly influenceable factors such as increasing height and mobility. Therefore, the aim of this study was to evaluate the therapeutic efficiency of the new adjustable gravitational valve, proSA. METHODS Sixty-four shunt-treated young hydrocephalus patients aged 1.8-41.4 years (15.5 ± 10.5 years) suffering from clinical and/or radiological overdrainage underwent shunt revision surgery with the implantation of the new proSA valve. Clinical outcome after a 1-year follow-up period, pumping function of the valve chambers as well as the number of necessary postoperative valve adjustments were examined. RESULTS Fifty-five patients completed the study as planned. All reported a significant improvement of their clinical condition; 91 % described a complete resolution in symptoms related to overdrainage. Preoperatively, more than 85 % of the valve chambers showed no or very slow refilling with CSF. After a year of proSA treatment, more than 90 % exhibited a normal valve chamber function. During the follow-up period, a total of 136 valve adjustments were necessary. None of the proSA valves had to be surgically revised. CONCLUSIONS The postoperative adjustability of the opening pressure level is the advantage of the new gravitational valve. The good clinical outcome is attributed to the new valve technology. The proSA appears to be a promising shunt valve to overcome overdrainage in adolescent and adult hydrocephalus patients.
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Affiliation(s)
- Christoph A Tschan
- Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar, Germany,
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Patients benefit from low-pressure settings enabled by gravitational valves in normal pressure hydrocephalus. Clin Neurol Neurosurg 2013; 115:1982-6. [DOI: 10.1016/j.clineuro.2013.06.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 05/24/2013] [Accepted: 06/09/2013] [Indexed: 11/22/2022]
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Gravity assisted vs. medium pressure valves for communicating hydrocephalus show similar valve-revision rates. Acta Neurochir (Wien) 2013; 155:1987-91. [PMID: 23989996 DOI: 10.1007/s00701-013-1852-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 08/17/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Two common valve types used to treat hydrocephalus include gravity assisted valves (GAV) and medium pressure valves (MPV). Despite their different mechanism of action, differentiated surgical indications per type are not well defined. One could assume that due to a higher complexity of the GAV system, it may be more prone to valve-related malfunction. The purpose of this retrospective study was to compare the valve-related complication rates of GAV and MPV in patients with communicating hydrocephalus. METHOD Patients aged 16 years or older undergoing their first shunt implantation using GAV or MPV were included. We recorded demographic data, implantation diagnosis, outcome, complications, valve type and valve adjustments. Symptoms were documented at discharge and follow-up. Valve-related malfunctions were distinguished from other shunt complications. RESULTS N = 252 patients (range 16.6-88.4, mean 65.0 years, 116 male and 136 female) underwent shunt placement for the first time. N = 122 GAV (48.4 %) and n = 130 MPV were implanted (51.6 %) over a period of 5 years. The most frequent diagnoses were normal pressure hydrocephalus (NPH) in 86 cases (34.1 %) and posthemorrhagic hydrocephalus in 114 cases (45.2 %). About two thirds of patients were free of hydrocephalus-related symptoms at follow-up. N = 66 subjects (26.2 %) underwent at least one shunt revision. N = 29 revisions (11.5 %) were due to valve-related malfunction. Valve-related revisions were the main cause for revision in 18/37 cases (48.6 %) in the GAV group and in 11/29 (37.9 %) in the MPV group. Neither clinical improvement nor valve-related malfunctions were found to be statistically different among groups. CONCLUSIONS Despite their technical differences, GAV and MPV show similar valve-related revision rates in the treatment of communicating hydrocephalus.
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Cordero Tous N, Román Cutillas AM, Jorques Infante AM, Olivares Granados G, Saura Rojas JE, Iañez Velasco B, Sánchez Corral C, Roldán Serrano MÁ, Horcajadas Almansa Á. Hidrocefalia crónica del adulto: diagnóstico, tratamiento y evolución. Estudio prospectivo. Neurocirugia (Astur) 2013; 24:93-101. [DOI: 10.1016/j.neucir.2011.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Accepted: 12/18/2011] [Indexed: 10/27/2022]
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Abstract
CLINICAL/METHODICAL ISSUE Modern treatment of hydrocephalus. STANDARDS OF CLINICAL AND RADIOLOGICAL METHODS: Clinically: shunting and endoscopy. Radiologically: MRT, CCT. METHODICAL INNOVATIONS Important innovations are gravitational valves and neuroendoscopy standing for new challenges in preoperative imaging and for sufficient interpretation of postoperative imaging. PERFORMANCE G-valves reduce the complication rate (especially overdrainage) in shunting significantly. While lacking appropriated clinical studies, the UK Shunt Registry still provides the best comparison between shunting and neuroendoscopy, after which the long-term revision rates of both methods are identical. The perioperative risk of endoscopic surgery seems to be higher than for shunts. ACHIEVEMENTS The superiority of the G-valves in chronic hydrocephalus in comparison with other valves has recently been demonstrated in a class 1 evidence-based study. The neuroendoscopy, has been,-in the absence of a contraindications -, indicated by a guidelines' committee of the German Society of Neurosurgery as method of choice in occlusive hydrocephalus alternatively to shunting. PRACTICAL RECOMMENDATIONS Preoperatively, to clarify etiology, comorbidity, and surgical planning, MRI is preferable; with planned neuroendoscopy as high-resolution detailed MRI of access-trajectory and region of interest. In post-operative CT or MRI (after endoscopic procedures always MRI) a differentiation between (sub-)acute and chronic hydrocephalus is important for correct interpretation of imaging: a normalization of ventricular size is physiological only in (sub-)acute hydrocephalus, in chronic hydrocephalus, yet, sign of overdrainage. In chronic hydrocephalus, ventricles shrink usually only marginally. Solely, better delineated, vertex-near cisternae are there evidence of sufficient drainage.
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Affiliation(s)
- M Kiefer
- Klinik für Neurochirurgie, Universitätsklinikum des Saarlandes, Homburg/Saar, Kirrbergerstraße, Homburg/Saar, Deutschland.
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Freimann FB, Sprung C. Shunting with gravitational valves—can adjustments end the era of revisions for overdrainage-related events? J Neurosurg 2012; 117:1197-204. [PMID: 22998061 DOI: 10.3171/2012.8.jns1233] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Overdrainage of CSF remains an unsolved problem in shunt therapy. The aim of the present study was to evaluate treatment options on overdrainage-related events enabled by the new generation of adjustable gravity-assisted valves.
Methods
The authors retrospectively studied the clinical course of 250 consecutive adult patients with various etiologies of hydrocephalus after shunt insertion for different signs and symptoms of overdrainage. Primary and secondary overdrainage were differentiated. The authors correlated the incidence of overdrainage with etiology of hydrocephalus, opening valve pressure, and patient parameters such as weight and size. Depending on the severity of overdrainage, they elevated the opening pressure, and follow-up was performed until overdrainage was resolved.
Results
The authors found 39 cases (15.6%) involving overdrainage-related problems—23 primary and 16 secondary overdrainage. The median follow-up period in these 39 patients was 2.1 years. There was no correlation between the incidence of overdrainage and any of the following factors: sex, age, size, or weight of the patients. There was also no statistical significance among the different etiologies of hydrocephalus, with the exception of congenital hydrocephalus. All of the “complications” could be resolved by readjusting the opening pressure of the valve in one or multiple steps, avoiding further operations.
Conclusions
Modern adjustable and gravity-assisted valves enable surgeons to set the opening pressure relatively low to avoid underdrainage without significantly raising the incidence of overdrainage and to treat overdrainage-related clinical and radiological complications without surgical intervention.
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Weinzierl MR, Hans FJ, Stoffel M, Oertel MF, Korinth MC. Experience with a gravitational valve in the management of symptomatic overdrainage in children with shunts. J Neurosurg Pediatr 2012; 9:468-72. [PMID: 22546023 DOI: 10.3171/2012.1.peds11110] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Symptomatic overdrainage in children with shunt-treated hydrocephalus represents one of the more difficult shunt-related diseases and may require repeated surgery. Gravity-assisted valve design has become a standard device to avoid overdrainage in many European pediatric hydrocephalus centers. However, the use of a gravitational valve for relieving symptoms associated with overdrainage has not yet been addressed. The goal of this study was to evaluate the effectiveness of a gravitational valve in the treatment of symptomatic overdrainage in children with shunts. METHODS Seventeen children with an adjustable shunt system and symptomatic overdrainage were treated by insertion of a gravitational valve. Clinical and radiological outcome were monitored for a minimum of 12 months after surgery. RESULTS Implantation of a gravitational valve resulted in either resolution (n = 12) or improvement (n = 5) of the symptoms. In 1 patient, symptoms remained almost unchanged and the gravitational valve had to be upgraded, resulting in resolution of the symptoms. During follow-up, the pressure setting of the adjustable differential pressure valve had to be changed in 7 patients. CONCLUSIONS The gravitational valve was effective in improving symptomatic overdrainage in the majority of patients in the present study. Because the ideal pressure setting for a given patient is hard to determine a priori, adjustable valve systems appear to be beneficial.
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Affiliation(s)
- Martin R Weinzierl
- Department of Neurosurgery, Technical University Munich, Klinikum rechts der Isar, Munich, Germany.
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Kiefer M, Unterberg A. The differential diagnosis and treatment of normal-pressure hydrocephalus. DEUTSCHES ARZTEBLATT INTERNATIONAL 2012; 109:15-25; quiz 26. [PMID: 22282714 DOI: 10.3238/arztebl.2012.0015] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Accepted: 11/18/2011] [Indexed: 01/18/2023]
Abstract
BACKGROUND Normal-pressure hydrocephalus (NPH) arises in adulthood and is characterized by a typical combination of clinical and radiological findings. The mean basal intracranial pressure is normal or mildly elevated. The typical signs of the disease are gait impairment, urinary incontinence, and dementia. The difficulty of distinguishing NPH from other neurodegenerative disorders is the likely reason why some 80% of cases remain unrecognized and untreated. According to current evidence, the spontaneous course of NPH ends, for the vast majority of patients, in dependence on nursing care. METHODS This review article is based on relevant publications retrieved by a selective search in Medline and on national and international guidelines for the management of NPH. RESULTS Studies with a high evidence level are lacking; thus, the current state of knowledge about NPH is derived from studies of low or intermediate evidence levels, e.g., observational studies. Modern forms of treatment lead to clinical improvement in 70% to 90% of treated patients. The treatment of choice is the implantation of a ventriculoperitoneal shunt. The differential diagnosis is complicated by the fact that three-quarters of patients with NPH severe enough to require treatment also suffer from another neurodegenerative disorder. Therefore, the clinical findings and imaging studies often do not suffice to establish the indication for surgery. To do this, a further, semi-invasive diagnostic procedure is recommended. Current risk/benefit analyses indicate that shunt operations improve outcome compared to the spontaneous course of the disease. CONCLUSION Normal pressure hydrocephalus should always enter into the differential diagnosis of patients who present with its characteristic manifestations. If the diagnosis of NPH is confirmed, it should be treated at an early stage.
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Affiliation(s)
- Michael Kiefer
- Klinik für Neurochirurgie, Universitätsklinikum des Saarlandes, Kirrberger Str., 66421 Homburg, Germany
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Lee WC, Seo DH, Choe IS, Park SC, Ha YS, Lee KC. A comparative result of ventriculoperitoneal shunt, focusing mainly on gravity-assisted valve and programmable valve. J Korean Neurosurg Soc 2010; 48:251-8. [PMID: 21082054 DOI: 10.3340/jkns.2010.48.3.251] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Revised: 08/16/2010] [Accepted: 09/17/2010] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Despite rapid evolution of shunt devices, the complication rates remain high. The most common causes are turning from obstruction, infection, and overdrainage into mainly underdrainage. We investigated the incidence of complications in a consecutive series of hydrocephalic patients. METHODS From January 2002 to December 2009, 111 patients underwent ventriculoperitoneal (VP) shunting at our hospital. We documented shunt failures and complications according to valve type, primary disease, and number of revisions. RESULTS Overall shunt survival time was 268 weeks. Mean survival time of gravity-assisted valve (GAV) was 222 weeks versus 286 weeks for other shunts. Survival time of programmable valves (264 weeks) was longer than that of pressure-controlled valves (186 weeks). The most common cause for shunt revision was underdrainage (13 valves). The revision rate due to underdrainage in patients with GAV (7 of 10 patients) was higher than that for other valve types. Of 7 patients requiring revision for GAV underdrainage, 6 patients were bedridden. The overall infection rate was 3.6%, which was lower than reported series. Seven patients demonstrating overdrainage had cranial defects when operations were performed (41%), and overdrainage was improved in 5 patients after cranioplasty. CONCLUSION Although none of the differences was statistically significant, some of the observations were especially notable. If a candidate for VP shunting is bedridden, GAV may not be indicated because it could lead to underdrainage. Careful procedure and perioperative management can reduce infection rate. Cranioplasty performed prior to VP shunting may be beneficial.
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Affiliation(s)
- Won-Chul Lee
- Department of Neurosurgery, Myongji Hospital, Kwandong University College of Medicine, Goyang, Korea
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Kiefer M, Eymann R. Clinical proof of the importance of compliance for hydrocephalus pathophysiology. ACTA NEUROCHIRURGICA. SUPPLEMENT 2010; 106:69-73. [PMID: 19812923 DOI: 10.1007/978-3-211-98811-4_11] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
INTRODUCTION Recently decreased compliance is discussed as an initially disturbed CSF hydrodynamic parameter in hydrocephalus. MATERIALS AND METHODS In 180 patients with suspected chronic hydrocephalus we performed a dynamic infusion test, which was not used for shunt indication. Shunt indication was based on long-term ICP monitoring. Follow-up was 4.6 +/- 1.8 years. STATISTICS Spearman-, Kruskal-Wallis-, Wilcoxen-U-test. RESULTS Resistance to outflow (Rout) and Pressure Volume Index (PVI) alone provide positive predictive values (PPV) and sensitivity, which might be sufficient in daily practice, while negative predictive values (NPV) and specificity are weak. With an intelligent combined algorithm of Rout and PVI at a critical value of ROF of 13 mm Hg/ml x min and 30 ml, a clearly improved outcome prediction is possible. CONCLUSION These clinical results support recent opinions concerning the meaning of Compliance and Rout in hydrocephalus patho-physiology.
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Affiliation(s)
- Michael Kiefer
- Department of Neurosurgery, Saarland University Medical School, Homburg-Saar, Germany.
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Kiefer M, Meier U, Eymann R. Does idiopathic normal pressure hydrocephalus always mean a poor prognosis? ACTA NEUROCHIRURGICA. SUPPLEMENT 2010; 106:101-6. [PMID: 19812929 DOI: 10.1007/978-3-211-98811-4_17] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The objective was to assess whether idiopathic normal-pressure hydrocephalus (iNPH) has a worse prognosis than other forms of hydrocephalus, as has been suggested. METHODS A total of 125 patients with chronic hydrocephalus, 75 of whom suffered from iNPH and the remaining (non-INPH) from sNPH or non-communicating hydrocephalus, were shunted using gravitational valves. Clinical state was assessed with our clinical grading (KI) and a co-morbidity index (CMI). Average follow-up was 5.1 +/- 1.6 years. STATISTICS Spearman, Kruskal-Wallis, ANOVA, chi(2)- and the Wilcoxon U tests at a significance level of pi < 0.05 were used. RESULTS Shunt responder rates for iNPH and non-iNPH were 72% and 86%, respectively. With shorter anamnesis (< or =1 year) or preoperative KI < 6 points, iNPH patients had a similar or even better outcome than non-iNPH patients with longer anamnesis or a worse KI. Most impressive was the influence of co-morbidity: 86% of iNPH patients with a low CMI (< or =3 points) experienced clinical improvement after shunting, which was contrasted by a responder rate of 64% for non-iNPH with worse CMI. CONCLUSION The diagnosis of iNPH does not by itself mean a worse prognosis, and iNPH patients with favorable preconditions may have a similar or better prognosis than patients with any other kind of hydrocephalus. The worse overall clinical results of iNPH result from late recognition and in most instances worse preconditions.
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Affiliation(s)
- Michael Kiefer
- Department of Neurosurgery, Saarland University Medical School, Homburg-Saar, Germany.
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Kiefer M, Eymann R. Gravitational shunt complications after a five-year follow-up. ACTA NEUROCHIRURGICA. SUPPLEMENT 2010; 106:107-112. [PMID: 19812930 DOI: 10.1007/978-3-211-98811-4_18] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
INTRODUCTION Gravitational shunts (G-valves) for ventriculo-peritoneal (VP) shunting have been available since 1996. We analyzed shunt complications in patients with a complete minimum follow-up of 5 years. MATERIAL AND METHODS Between 1996 and 2002, we implanted 282 VP G-valves in various forms of adult chronic hydrocephalus, of which 130 provided a complete data set with an annual follow-up. Adjustable and non-adjustable G-valves were used: the Miethke Dual-Switch valve, the Miethke GAV-valve and a combination of adjustable Codman-Hakim valves with the Miethke Shunt-Assistant. In cases of supposed mechanical shunt failure, the explanted shunts were examined in a bench test. RESULTS The total complication rate was 21%:3% shunt infections, 3% catheter dislocation/fracture, 5% underdrainage and 9% overdrainage occurred. Half of the overdrainage complications could be managed conservatively. Underdrainage complications resulted from the chosen opening pressure being too high (n = 3), a secondary increase in intraperitoneal pressure (n = 2) or from "real" shunt failure in one case according to bench test results. CONCLUSION G-valves demonstrate sufficient long-term performance over multiple years, and real shunt-related complications are rare. The frequency of revision due to overdrainage is low (4.5%).
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Affiliation(s)
- Michael Kiefer
- Department of Neurosurgery, Saarland University Medical School, Homburg-Saar, Germany.
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Developmental and Acquired Anomalies. Neurosurgery 2010. [DOI: 10.1007/978-3-540-79565-0_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Meier U, Lemcke J. Co-morbidity as a Predictor of Outcome in Patients with Idiopathic Normal-Pressure Hydrocephalus. BRAIN EDEMA XIV 2010; 106:127-30. [DOI: 10.1007/978-3-211-98811-4_22] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Deininger MH, Weyerbrock A. Gravitational valves in supine patients with ventriculo-peritoneal shunts. Acta Neurochir (Wien) 2009; 151:705-9; discussion 709. [PMID: 19337679 DOI: 10.1007/s00701-009-0291-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Accepted: 12/11/2008] [Indexed: 11/29/2022]
Abstract
BACKGROUND In the subgroup of bedridden hydrocephalic patients with ventriculo-peritoneal shunts and gravitational valves, we occasionally observed persisting hydrocephalic complaints even when mechanical or infection-related obstruction was excluded. METHODS To investigate the cause of these hydrocephalic symptoms, in vitro and in vivo analyses were used to determine valve opening, intra-abdominal and hydrostatic pressure of an Aesculap-Miethke 10/40 cm H2O gravitational valve at different angles of upper body and head inclination. FINDINGS Since hydrostatic pressure is lacking, the resulting intra-ventricular pressures are shown to peak up to 27 cm H2O in supine patients with head, but not upper body inclined. CONCLUSIONS We conclude that in the subgroup of bedridden patients with ventriculo-peritoneal shunts and gravitational valves, upright posture is a prerequisite for proper cerebrospinal fluid drainage.
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Affiliation(s)
- Martin H Deininger
- Department of Neurosurgery, University of Freiburg Medical School, Breisacher Str. 64, D-79106 Freiburg, Germany.
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Kaestner S, Kruschat T, Nitzsche N, Deinsberger W. Gravitational shunt units may cause under-drainage in bedridden patients. Acta Neurochir (Wien) 2009; 151:217-21; discussion 221. [PMID: 19238319 DOI: 10.1007/s00701-009-0215-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2008] [Accepted: 02/06/2009] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Implantation of a shunt in a hydrocephalic patient still carries a risk of complications such as over-drainage and under-drainage. Gravitational shunt units are especially designed to minimize the problem of over-drainage. Nevertheless, these valves carry a risk of under-drainage. The best choice of valve for a patient is still challenging. The purpose of this survey was to identify in which patients a gravitational shunt valve is liable to lead to under-drainage. METHODS Patients with hydrocephalus entered prospectively into a data base were reviewed retrospectively. The patients were treated between January 2006 to the end of Feb 2007 and those experiencing under- or over-drainage were identified. RESULTS Thirty-five ventriculo-peritoneal shunt systems were implanted in adult patients. The cause of the hydrocephalus was: normal pressure hydrocephalus in 18 patients, post-haemorrhagic following subarachnoid or intracerebral haemorrhage in 11, associated with a tumour in four and followed a head injury in two patients. Three different valves were used: an adjustable shunt valve with gravitational unit (Pro-GAV 0-20/25 in 21 patients), a gravitational shunt valve with fixed opening pressure (GAV 5/30 in nine patients) and an adjustable differential valve (Hakim medos in five patients). Four patients developed severe, valve-related under-drainage. Each had received a gravitational shunt valve and all were bedridden. In two of these patients it was necessary to change the valve. One patient who had received a differential valve, after regaining mobility developed severe over-drainage with bilateral subdural haematomas. Over-drainage was not seen in long-term bedridden patients with a differential shunt valve. CONCLUSION If a bedridden patient with a gravitational shunt valve system lies with a slightly elevated head, this leads to activation of the gravitational unit and this may cause under drainage. As a result, we advise not using an anti-siphon devices in a patient who is bedridden for a long period.
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Affiliation(s)
- S Kaestner
- Department of Neurosurgery, Klinikum Kassel, Kassel, Germany.
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Ishikawa M, Hashimoto M, Kuwana N, Mori E, Miyake H, Wachi A, Takeuchi T, Kazui H, Koyama H. Guidelines for management of idiopathic normal pressure hydrocephalus. Neurol Med Chir (Tokyo) 2008; 48 Suppl:S1-23. [PMID: 18408356 DOI: 10.2176/nmc.48.s1] [Citation(s) in RCA: 146] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
With the rapid aging of Japanese society, medical care of the elderly has become an important social issue. Among various disorders manifesting dementia, gait disturbance, and urinary incontinence in the elderly population, normal pressure hydrocephalus (NPH), especially of idiopathic type (iNPH), is becoming noteworthy. The Guidelines for management of iNPH in Japan are created in compliance with the evidence-based medicine methods and published in 2004. This English version is made to show the diagnosis and treatment of iNPH with reference to the socio-medical background in Japan and to promote the international research on iNPH. They propose three diagnostic levels; possible, probable, and definite. They indicate the diagnostic importance of high convexity tightness and dilated sylvian fissure with mild to moderate ventriculomegaly on coronal magnetic resonance imaging. The cerebrospinal fluid tap test is regarded as an important diagnostic test because of its simplicity to perform and high predictability of the shunt efficacy. The use of programmable valves at shunt surgeries is recommended. Flowcharts for diagnosis, preoperative assessment, and prevention for complications of shunt surgery are made to promote a wide use of them.
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Stein SC, Guo W. A mathematical model of survival in a newly inserted ventricular shunt. J Neurosurg 2008; 107:448-54. [PMID: 18154010 DOI: 10.3171/ped-07/12/448] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The object of this study was to mathematically model the prognosis of a newly inserted shunt in pediatric or adult patients with hydrocephalus. METHODS A structured search was performed of the English-language literature for case series reporting shunt failure, patient mortality, and shunt removal rates after shunt insertion. A metaanalytic model was constructed to pool data from multiple studies and to predict the outcome of a shunt after insertion. Separate models were used to predict shunt survival rates for children (patients < 17 years old) and adults. RESULTS Shunt survival rates in children and adults were calculated for 1 year (64.2 and 80.1%, respectively), 5 years (49.4 and 60.2%, respectively), and the median (4.9 and 7.3 years, respectively). The longer-term rates predicted by the model agree closely with those reported in the literature. CONCLUSIONS This model gives a comprehensive view of the fate of a shunt for hydrocephalus after insertion. The advantages of this model compared with Kaplan-Meier survival curves are discussed. The model used in this study may provide useful prognostic information and aid in the early evaluation of new shunt designs and techniques.
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Affiliation(s)
- Sherman C Stein
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19106, USA.
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Meier U, Lemcke J, Al-Zain F. Course of disease in patients with idiopathic normal pressure hydrocephalus (iNPH): a follow-up study 3, 4 and 5 years following shunt implantation. ACTA NEUROCHIRURGICA. SUPPLEMENT 2008; 102:125-7. [PMID: 19388302 DOI: 10.1007/978-3-211-85578-2_25] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND In spite of recent advances in the diagnosis and treatment of iNPH, favorable outcomes following CSF diversion continue to be limited by complications, both valve dependent and valve independent, as well as by a reduction, over time, in the response to shunting. MATERIALS AND METHODS Between September 1997 and December 2006, 148 patients underwent ventriculo-peritoneal shunt surgery in our department. All patients underwent the implantation of gravitational valves. These patients were followed-up 3, 6 and 12 months after surgery and then at annual intervals. FINDINGS The mean age of the 94 men and 54 women in our study was 68 years. The perioperative mortality was 0.7% (one patient died from a pulmonary embolism). A further 23 patients died during the follow-up period from causes unrelated to iNPH or the surgery. This study reports on groups of patients followed-up for 2 years (n = 92), 3 years (n = 62), 4 years (n = 38) and 5 years (n = 21) postoperatively. Valve independent complications occurred postoperatively in 6% of patients (n = 10). Of these, five patients (3% of the total) had an infection and catheter displacement was recorded in a further five. Valve dependent complications occurred in 24 patients (16%), with overdrainage found in seven patients (5%) and underdrainage apparent in 17 (11%). Responder rates were 79% at 2 years, 79% at 3 years, 64% at 4 years and 60% at 5 years. The optimal valve opening pressure in programmable valves with a gravitational unit was between 30 and 70 mmHg. CONCLUSIONS Sixty percent of patients with iNPH who underwent a ventriculo-peritoneal shunt using a gravitational valve continue to benefit from surgery 5 years postoperatively.
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Affiliation(s)
- U Meier
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Strasse 7, 12683 Berlin, Germany.
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Meier U, Lemcke J. The influence of co-morbidity on the postoperative outcomes of patients with idiopathic normal pressure hydrocephalus (iNPH). ACTA NEUROCHIRURGICA. SUPPLEMENT 2008; 102:141-4. [PMID: 19388306 DOI: 10.1007/978-3-211-85578-2_29] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND A critical question in the diagnosis and treatment of idiopathic normal pressure hydrocephalus (iNPH) is that of which preoperative factors can most reliably predict outcomes following shunt insertion. The number and type of co-morbidities are increasingly being viewed as important predictive indicators. METHODS Between 1997 and 2004, 95 patients were implanted with a gravitational ventriculo-peritoneal shunt as treatment for iNPH. All coincident disease processes were recorded. Eighty-two of these patients underwent follow-up 2 years postoperatively. The results of this prospective follow-up examination (Kiefer Score, NPH Recovery Rate) were compared with the preoperative CoMorbidity Index (CMI). FINDINGS Of the patients with a CMI score of 0-1 (n = 18), 67% experienced an excellent outcome, 28% a good outcome and 5% and 0% a fair and poor outcome respectively. A CMI score of 2-3 was associated with markedly poorer outcomes (n = 33); 42% excellent, 30% good, 18% fair and 10% poor. A score of 4-5 was related to 14% excellent, 27% good, 23% fair and 36% poor outcomes (n = 22). Remarkably few patients scoring between 6 and 8 on the CMI scale experienced a favourable outcome. The outcomes for this latter group were 0% excellent, 10% good, 45% fair and 45% poor (n = 9) significant predictor of the quality of clinical outcome for patients with iNPH undergoing shunt therapy.
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Affiliation(s)
- U Meier
- Department of Neurosurgery, Unfallkrankenhaus Berlin, Warener Strasse 7, 12683 Berlin, Germany.
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Abstract
OBJECT The goal of this study was to determine whether failure rates of hydrocephalus shunts have fallen over the years as a result of experience or technical improvements. METHODS A structured search was performed of the English language literature for case series reporting failure rates after shunt insertion. A metaanalytic model was constructed to pool data from multiple studies and to analyze failure rates statistically for temporal trends. Separate models were used for children (< 17 years old) and adults. RESULTS In children, the shunt failure rate was 31.3% for the 1st year and 4.5% per year thereafter. There were no significant changes in either rate over time. Although 1st-year failure rates in adults have fallen slightly over time, late failure rates have risen. CONCLUSIONS Progress in preventing shunt failures has not been made over the last several decades. Any improvements made in shunt materials or insertion techniques have been overshadowed by biological and other factors.
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Affiliation(s)
- Sherman C Stein
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19106, USA.
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Park J, Kim GJ, Hwang SK. Valve inclination influences the performance of gravity-assisted valve. ACTA ACUST UNITED AC 2007; 68:14-8; discussion 18. [PMID: 17586212 DOI: 10.1016/j.surneu.2006.10.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2005] [Accepted: 10/05/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND The performance of GAV may be affected by its inclination as a tantalum sphere in the valve, which generates a downhill force in proportion to the sine of the angle with respect to level. Accordingly, the aim of this study was to evaluate the effect of valve inclination relative to the vertical on shunt performance. METHOD In 24 adult patients who underwent ventriculoperitoneal shunting using a GAV for hydrocephalus, valve inclination relative to the vertical was measured using AP and lateral projections of skull x-rays that were taken in a standing position, and the relationship between valve inclination and ventricular volume change after ventriculoperitoneal shunting in CT scans was evaluated. RESULTS The Pearson correlation coefficient between valve inclination in a sagittal plane and ventricular volume change was -0.768 (P < .01), whereas lateral valve inclination had no correlation with ventricular volume change. Eleven patients with a posterior valve inclination relative to the vertical exhibited a greater ventricular volume reduction of 34.1% +/- 8.2% compared to the volume reduction of 13.4% +/- 9.2 % in 13 other patients with an anterior valve inclination (P = .000). Two (40%) of 5 patients with a severe anterior valve inclination of more than 20 degrees relative to the vertical underwent shunt revision for underdrainage. CONCLUSIONS A severe anterior inclination of the valve by more than 20 degrees relative to the vertical can lead to underdrainage owing to an increased OP in a lying position, especially in patients who are nonambulatory at the time of GAV implantation.
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Affiliation(s)
- Jaechan Park
- Department of Neurosurgery, Kyungpook National University, Daegu, 700-721, Republic of Korea.
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Eymann R, Steudel WI, Kiefer M. Pediatric gravitational shunts: initial results from a prospective study. J Neurosurg 2007; 106:179-84. [PMID: 17465381 DOI: 10.3171/ped.2007.106.3.179] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors' goal in this paper was to evaluate prospectively the efficacy and safety of a new pediatric gravitational shunt to determine whether it warrants inclusion in a randomized, controlled trial with other shunts. METHODS A total of 55 children between the ages of 0 and 6 years (median age 0.5 years, average age 4+/-6 years) underwent primary shunt implantation; all received the Miethke Paedi-GAV. The follow-up period ranged between 12 and 77 months (mean 47+/-21 months). The primary end point of the study was the first shunt failure necessitating revision. The 1- and 2-year shunt survival rates were 75 and 68%, respectively. The average failure-free shunt survival duration was 1423 +/- 641 days. Based on imaging findings, no slitlike ventricles occurred. The complication rate was 33%, and the median time to shunt failure was 45 days. Underdrainage occurred in one child (1.8%) and overdrainage in two children (3.6%). CONCLUSIONS These preliminary results prove the Miethke Paedi-GAV to be a safe and effective pediatric shunt worthy of inclusion in a randomized comparison with other shunts in the pediatric population.
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Affiliation(s)
- Regina Eymann
- Department of Neurosurgery, Saarland University Medical School, Saarland, Germany.
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Stein SC, Burnett MG, Sonnad SS. Shunts in normal-pressure hydrocephalus: do we place too many or too few? J Neurosurg 2007; 105:815-22. [PMID: 17405250 DOI: 10.3171/jns.2006.105.6.815] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The average 65-year-old patient with moderate dementia can look forward to only 1.4 quality-adjusted life years (QALYs), that is, longevity times quality of life. Some of these patients suffer from normal-pressure hydrocephalus (NPH) and respond dramatically to shunt insertion. Currently, however, NPH cannot be diagnosed with certainty. The authors constructed a Markov decision analysis model to predict the outcome in patients with NPH treated with and without shunts. METHODS Transition probabilities and health utilities were obtained from a review of the literature. A sensitivity analysis and Monte Carlo simulation were applied to test outcomes over a wide range of parameters. Using shunt response and complication rates from the literature, the average patient receiving a shunt would gain an additional 1.7 QALYs as a result of automatic shunt insertion. Even if 50% of patients receiving a shunt have complications, the shunt response rate would need to be less than 5% for empirical shunt insertion to do more harm than good. Authors of most studies have reported far better statistics. CONCLUSIONS In summary, many more patients with suspected NPH should be considered for shunt insertion.
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Affiliation(s)
- Sherman C Stein
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Abstract
OBJECT The management of hydrocephalus can be challenging because of the unique cerebrospinal fluid (CSF) dynamics in each patient. Various shunt systems have been developed for the treatment of hydrocephalus. One of the main issues surrounding these systems is overshunting due to siphoning. In this paper the authors discuss the pathophysiology of CSF siphoning as well as the various devices used to treat this problem. The pros and cons of each device are discussed, as are the key differences among them. Future concepts are also introduced with an emphasis on upcoming device designs. METHODS The authors performed a literature review of articles addressing CSF dynamics, shunting, and regulatory devices. The literature consisted of original research articles, company literature on each device, and patent information. A number of siphon regulatory devices have been developed over the past two decades. Each device has a distinct design, requiring specific techniques of implantation for optimal function. CONCLUSIONS For the past two decades, a variety of siphon regulatory devices have been used to help deal with CSF siphoning. With the increasing mobility of the population, every neurosurgeon will be seeing patients with older and newer devices. Familiarity with the various devices will assist in the evaluation and care of these patients.
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Affiliation(s)
- Khalid H Kurtom
- Department of Neurosurgery, George Washington University Hospital Washington, DC, USA.
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Clinical Experience in the Treatment of Idiopathic Normal-pressure Hydrocephalus Using the Programmable Gravity-assisted Valve (ProGAVAesculap). ACTA ACUST UNITED AC 2007. [DOI: 10.1097/wnq.0b013e3180331759] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kondageski C, Thompson D, Reynolds M, Hayward RD. Experience with the Strata valve in the management of shunt overdrainage. J Neurosurg Pediatr 2007; 106:95-102. [PMID: 17330533 DOI: 10.3171/ped.2007.106.2.95] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The overdrainage of cerebrospinal fluid (CSF) in children with shunt-treated hydrocephalus may cause chronic disabling symptoms and require repeated surgery. Externally adjustable valves offer a noninvasive way of altering the valve opening pressure. The authors report on their experience with using the Strata valve in the management of symptomatic CSF overdrainage. METHODS The authors treated 24 patients with symptomatic CSF overdrainage by inserting a Strata valve. The severity of symptoms was graded, and the frequency of hospital visits and shunt operations was recorded before and after insertion of the valve. Additionally, results of brain imaging and intracranial pressure monitoring were reviewed. Nineteen patients (79.2%) had severe symptoms at the time of the insertion; 1 year after Strata valve insertion only one patient (4.17%) still suffered severe symptoms. The number of hospital admissions was 3.38/patient/year before placement and 1.21 for the 1st year, 1 for the 2nd, and 0.4 for the 3rd postoperative year. The number of operations was 3.42/patient/year during the year before placement of the valve, and then 0.71 for the 1st, 0.56 for the 2nd, and 0.25 for the 3rd postoperative years. During the 1st year after placement of the Strata valve, the settings were changed 2.79 times/patient/year, 1.29 for the 2nd, and 1.33 times/patient/year for the 3rd year. CONCLUSIONS The Strata valve was effective in improving the symptoms of overdrainage in the majority of patients in this series. The number of hospital admissions and operations for valve malfunction was reduced.
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Affiliation(s)
- Charles Kondageski
- Department of Pediatric Neurosurgery, Great Ormond Street Hospital for Children, London, United Kingdom
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Kiefer M, Eymann R, Steudel WI. Outcome predictors for normal-pressure hydrocephalus. ACTA NEUROCHIRURGICA. SUPPLEMENT 2006; 96:364-7. [PMID: 16671486 DOI: 10.1007/3-211-30714-1_75] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The objective of this prospective study was to find outcome predictors for better selection for treatment of normal-pressure hydrocephalus (NPH) patients. A total of 125 patients were evaluated and provided with a gravitational shunt. Cerebrospinal fluid hydrodynamics provided better predictive values if an algorithm to shunt all patients with a pressure/volume index of < 30 mL or resistance to outflow > 13 mmHg/mL x min was used. In general, outcome became worse with increasing anamnesis duration, worse preoperative clinical state, and increasing comorbidity. If one of these parameters was lower than a critical value, the shunt-responder rate was about 90% and the normally negative influence of older age was not seen. The well-known paradigm of a worse prognosis with NPH is not the result of the hydrocephalus etiology itself, but the consequence of a typical accumulation of negative outcome predictors as a consequence of the misinterpretation of normal aging and delayed adequate treatment.
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Affiliation(s)
- M Kiefer
- Saarland University, Medical School, Department of Neurosurgery, Homburg-Saar, Germany.
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Kiefer M, Eymann R, Strowitzki M, Steudel WI. Gravitational shunts in longstanding overt ventriculomegaly in adults. Neurosurgery 2006; 57:109-19; discussion 109-19. [PMID: 15987546 DOI: 10.1227/01.neu.0000134596.66114.e7] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2003] [Accepted: 05/06/2004] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE A new entity of chronic hydrocephalus was introduced recently in the international literature: longstanding overt ventriculomegaly in adults. Previous experience with this disorder has demonstrated that shunt therapy for such patients involves a considerable risk of overdrainage. In the present study, we aimed to clarify whether this risk could be avoided by use of gravitational shunts. METHODS A total of 26 adults (age range, 17-75 yr) with macrocephaly and progressive hydrocephalus symptoms underwent implantation of either an adjustable Codman Hakim gravity-assisted shunt (Codman Medos, LeLocle, Switzerland) plus an Aesculap-Miethke ShuntAssistant (Miethke KG, Kleinmachnow, Germany) or a nonadjustable gravitational shunt (Aesculap-Miethke gravity-assisted valve). The follow-up period averaged 29 +/- 13 months (range, 6-48 mo). RESULTS Significant sustained clinical improvement was achieved in 87% of patients. In more than 90% of patients, Evans index decreased postoperatively by less than 10%. No correlation was documented between the degree of ventricle width reduction and clinical improvement. Only two patients developed subdural hematoma, which was caused by insufficient hydrostatic pressure compensation owing to errors in estimation of intraperitoneal pressure. CONCLUSION Unlike conventional differential pressure shunts, gravitational shunts can be used in the treatment of high-risk patients with longstanding overt ventriculomegaly in adults. Significant risk of overdrainage can be avoided. Gravitational shunts offer a viable alternative to endoscopic third ventriculostomy, provided the choice and adjustment of the shunt opening pressure is based on a correct assessment of the hydrostatic pressure to be compensated for.
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Affiliation(s)
- Michael Kiefer
- Department of Neurosurgery, Saarland University Medical School, Homburg/Saar, Germany.
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