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Chen KH, Hsu PW, Wu BC, Tu PH, Wang YC, Lee CC, Huang YC, Chen CC, Chuang CC, Liu ZH. Long-term follow-up and comparison of programmable and non-programmable ventricular cerebrospinal fluid shunts among adult patients with different hydrocephalus etiologies: a retrospective cohort study. Acta Neurochir (Wien) 2023; 165:2551-2560. [PMID: 37553445 PMCID: PMC10477099 DOI: 10.1007/s00701-023-05734-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/22/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Programmable valve (PV) has been shown as a solution to the high revision rate in pediatric hydrocephalus patients, but it remains controversial among adults. This study is to compare the overall revision rate, revision cause, and revision-free survival between PV and non-programmable valve (NPV) in adult patients with different hydrocephalus etiologies. METHOD We reviewed the chart of all patients with hydrocephalus receiving index ventricular cerebrospinal fluid (CSF) shunt operations conducted at a single institution from January 2017 to December 2017. Patients included in the study were followed up for at least 5 years. Statistical tests including independent t-test, chi-square test, and Fisher's exact test were used for comparative analysis, and Kaplan-Meier curve using log-rank test was performed to compare the revision-free survival between the PV and NPV groups. RESULTS A total of 325 patients were included in the study, of which 181 patients were receiving PVs and 144 patients receiving NPV. There were 23 patients (12.8%) with PV and 22 patients (15.3%) with NPV receiving initial revision. No significant statistical difference in the initial revision rate was observed between the two groups (p = 0.52). No survival difference was found between the PV and NPV groups. However, better revision-free survival was noted in the PV group among idiopathic normal pressure hydrocephalus (iNPH) (p = 0.0274) and post-traumatic hydrocephalus (p = 0.017). CONCLUSIONS The combination of the different etiologies of hydrocephalus and the features of PV and NPV results in different outcomes-revision rate and revision-free survival. PV use might be superior to NPV in iNPH and post-traumatic hydrocephalus patients. Further studies are needed to clarify the indications of PV use in adult hydrocephalus patients.
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Affiliation(s)
- Kuan-Hung Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Peng-Wei Hsu
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Bo-Chang Wu
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Po-Hsun Tu
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Yu-Chi Wang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Cheng-Chi Lee
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Yin-Cheng Huang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Ching-Chang Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Chi-Cheng Chuang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan
| | - Zhuo-Hao Liu
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Chang Gung Medical College and University, Taoyuan, Taiwan.
- School of Medicine, National Tsing Hua University, Hsinchu, Taiwan.
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Wipplinger C, Griessenauer CJ. Commentary: A Cohort Comparison Analysis of Fixed Pressure Ventriculoperitoneal Shunt Valves With Programmable Valves for Hydrocephalus Following Nontraumatic Subarachnoid Hemorrhage. Oper Neurosurg (Hagerstown) 2020; 18:E102-E103. [PMID: 31745556 DOI: 10.1093/ons/opz264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 06/08/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Christoph J Griessenauer
- Department of Neurosurgery and Neuroscience Institute, Geisinger, Danville, Pennsylvania.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
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Sandvig A, Arnell K, Malm J, Eklund A, Koskinen LOD. Analysis of Codman microcerebrospinal fluid shunt. Brain Behav 2018; 8:e01002. [PMID: 30207083 PMCID: PMC6192409 DOI: 10.1002/brb3.1002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 03/18/2018] [Accepted: 04/15/2018] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Ventriculo-peritoneal cerebrospinal fluid (CSF) shunt is the most common method of treating pediatric hydrocephalus. The Codman microadjustable valve (CMAV) is a CSF shunt constructed for children. The objective of the study was (a) to analyze complications after insertion of a CMAV shunt in hydrocephalic children, (b) to analyze complications after replacing a CMAV by an adult-type Codman Hakim adjustable valve shunt (CHAV), and to (c) analyze the in vitro characteristics of the CMAV shunt and correlate the findings with the clinical performance of the shunt. METHODS A retrospective study analyzed a cohort of hydrocephalic children who had received a CMAV shunt and later replaced by a CHAV shunt. We report on the complications that resulted from replacing the CMAV with the CHAV. We tested six CMAV shunts with or without an antisiphon device (ASD) in which opening pressure, resistance, sensitivity to abdominal pressure, ASD position dependency, and function were determined. The test results were correlated with the clinical performance of the shunt in the retrospective study. RESULTS Thirty-seven children (19 boys, 18 girls) were identified. Within the first month after shunt placement, a total of 10 patients (27%) developed complications including infections, hygromas, and shunt dysfunction. Shunt survival varied from 1 week to 145 months. Over the 10-year follow-up period, 13 children had their shunts replaced, six of them with a CHAV without any further complications. A bench test of the CMAV was done to test whether the opening pressure was in agreement with the manufacturer's specifications. Our results were generally in agreement with specifications stated by the manufacturer. CONCLUSION Replacing a CMAV with a CHAV was well tolerated by the patients. Bench test results were generally in agreement with manufacturers specifications. Replacing a CMAV with a CHAV in pediatric hydrocephalus patients can be accomplished safely.
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Affiliation(s)
- Axel Sandvig
- Department of Pharmacology and Clinical Neurosciences, Division of Neuro, Head and Neck, Umeå University, Umeå, Sweden.,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kai Arnell
- Department of Surgery, Umeå University, Umeå, Sweden
| | - Jan Malm
- Department of Pharmacology and Clinical Neurosciences, Division of Neuro, Head and Neck, Umeå University, Umeå, Sweden
| | - Anders Eklund
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Lars-Owe D Koskinen
- Department of Pharmacology and Clinical Neurosciences, Division of Neuro, Head and Neck, Umeå University, Umeå, Sweden
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Li M, Wang H, Ouyang Y, Yin M, Yin X. Efficacy and safety of programmable shunt valves for hydrocephalus: A meta-analysis. Int J Surg 2017. [PMID: 28648796 DOI: 10.1016/j.ijsu.2017.06.078] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Shunt implantation is an option in the treatment of hydrocephalus. However, the benefits and adverse effects of programmable shunt valves have not been well assessed. MATERIALS AND METHODS Randomized controlled trials (RCTs) and observational studies assessing the efficacy and safety of programmable valves (PV) treatment for hydrocephalus were identified from electronic databases (PubMed, EMBASE, and Cochrane library). The meta-analysis was performed with the fixed-effect model or random-effect model according to heterogeneity. RESULTS Three RCTs and eight observational studies met the inclusion criteria including 2622 subjects. Compared with non-PV, PV treatment did not have a statistically significant effect on one-year shunt survival rate [relative risk (RR), 1.06; 95% confidence interval (CI), 0.84-1.35], Substantial heterogeneity was observed between studies (P = 0.09; I2 = 65%). PV administration significantly reduced revision rate (RR, 0.56; 95% CI, 0.45-0.69; I2 = 29%; P = 0.23) and over- or under-drainage complications rate (RR, 0.55; 95% CI, 0.32-0.96). PV was not associated with increased rates of other adverse events, including overall complications rate, infection rate and catheter-related complications rate. CONCLUSIONS PV treatment is safe and may reduce the revision rate and over- or under-drainage complication rate, especially in patients aged less than 18 years with hydrocephalus. PV treatment is not associated with decreased overall complication rates in patients with hydrocephalus, but the trial sequential analysis indicate more studies are needed to confirm this result.
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Affiliation(s)
- Min Li
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, People's Republic of China
| | - Han Wang
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, People's Republic of China
| | - Yetong Ouyang
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, People's Republic of China
| | - Min Yin
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, People's Republic of China
| | - Xiaoping Yin
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, People's Republic of China.
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Hanak BW, Bonow RH, Harris CA, Browd SR. Cerebrospinal Fluid Shunting Complications in Children. Pediatr Neurosurg 2017; 52:381-400. [PMID: 28249297 PMCID: PMC5915307 DOI: 10.1159/000452840] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 10/25/2016] [Indexed: 12/11/2022]
Abstract
Although cerebrospinal fluid (CSF) shunt placement is the most common procedure performed by pediatric neurosurgeons, shunts remain among the most failure-prone life-sustaining medical devices implanted in modern medical practice. This article provides an overview of the mechanisms of CSF shunt failure for the 3 most commonly employed definitive CSF shunts in the practice of pediatric neurosurgery: ventriculoperitoneal, ventriculopleural, and ventriculoatrial. The text has been partitioned into the broad modes of shunt failure: obstruction, infection, mechanical shunt failure, overdrainage, and distal catheter site-specific failures. Clinical management strategies for the various modes of shunt failure are discussed as are research efforts directed towards reducing shunt complication rates. As it is unlikely that CSF shunting will become an obsolete procedure in the foreseeable future, it is incumbent on the pediatric neurosurgery community to maintain focused efforts to improve our understanding of and management strategies for shunt failure and shunt-related morbidity.
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Affiliation(s)
- Brian W. Hanak
- Department of Neurological Surgery, University of Washington and Seattle Children’s Hospital, Seattle, WA
| | - Robert H. Bonow
- Department of Neurological Surgery, University of Washington and Seattle Children’s Hospital, Seattle, WA
| | - Carolyn A. Harris
- Department of Neurosurgery, Wayne State University and Children’s Hospital of Michigan, Detroit, MI, USA
| | - Samuel R. Browd
- Department of Neurological Surgery, University of Washington and Seattle Children’s Hospital, Seattle, WA
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Feasibility Analysis for Treatment of Giant Intracranial Benign Tumor by Delayed Operation in Infancy. World Neurosurg 2016; 99:122-131. [PMID: 27939796 DOI: 10.1016/j.wneu.2016.11.140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 11/27/2016] [Accepted: 11/28/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The survival rate and prognosis in infants with giant intracranial tumors are significantly worse than in older children. This study aimed to analyze the feasibility of delayed operation for infants with giant intracranial benign tumor by evaluating the initial clinical presentations, expectant treatment measures, perioperative vital signs, and recuperation after surgery. PATIENTS AND DATA We reviewed 3 infant patients (average age, 9.33 months; range, 5-12 months) with giant intracranial benign tumors during January 2015 and April 2016. The maximum sections of tumors were 38 × 50 mm, 57 × 39 mm, and 55 × 67 mm, respectively. All clinical presentations, neuroimaging, and laboratory examinations were recorded. RESULTS Obstructive hydrocephalus was observed in 2 infants; ventriculoperitoneal shunts were placed in both before the delayed tumor resection. The disease progressed rapidly in the infant with teratoma and surgery was performed 4 months after placement of the ventriculoperitoneal shunt. The other 2 patients had experienced a 12-month growth and developmental phase and later underwent operations. Gross total resection was achieved in all patients. The pathologic results were consistent with the preoperative diagnosis. During a period of high-quality postoperative care, they remained stable and were discharged without any complications or neurologic deficits, and continued to improve toward their baseline. CONCLUSIONS Delayed operation enabled infant patients to gain a better physical state, with a stage of full preoperative preparation that may reduce intraoperative/postoperative morbidity and mortality.
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Symss NP, Oi S. Is there an ideal shunt? A panoramic view of 110 years in CSF diversions and shunt systems used for the treatment of hydrocephalus: from historical events to current trends. Childs Nerv Syst 2015; 31:191-202. [PMID: 25547875 DOI: 10.1007/s00381-014-2608-z] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Accepted: 12/09/2014] [Indexed: 11/24/2022]
Abstract
OBJECT The goal of this study is to evaluate whether an "ideal shunt" exists. METHODS This is a retrospective analysis based on original papers in the field of Hydrocephalus and Shunts. Patients of all age groups, who had hydrocephalus, and underwent some form of CSF diversion were included. The study has been divided into four stages: from 1900 to 1949, 1950 to 1974, 1975 to 1999, and from 2000 to 2010. RESULTS In stage 1 (historical era): Saphenous vein grafts, rubber conduits, and other materials were used in CSF diversions. In 1949, the first implantable shunt tube was developed by Nulsen. In stage 2 (experimental stage): the Holter valve was developed. Newer innovations were developed in relation to the ventriculo-atrial shunt, which was the preferred CSF diversion. In stage 3 (developmental stage), a large number of different design shunt systems were developed, with the aim of reducing complications. The ventriculo-peritoneal shunt had become the preferred CSF diversion. Also, the programmable valve was born. In stage 4 (era of programmable valve, there is a preference for the use of programmable shunt systems. However, shunt failure rate at 1 year being around 25 to 40%, and shunt survival at 1 and 2 years are 50-70 and 47-53% in most series. CONCLUSION Every shunt is an ideal shunt provided the choice of the shunt used should be made by the matching performance of the shunt system to the altered profile of CSF dynamics of a given patient. The most important factor being the opening pressure.
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Affiliation(s)
- Nigel Peter Symss
- Division of Pediatric Neurosurgery, Global Neurosciences, Global Health City, Cheran Nagar, Perumbakkam, Sholinganallur Road, Chennai, 600 100, Tamil Nadu, India,
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Baird LC, Mazzola CA, Auguste KI, Klimo P, Flannery AM. Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 5: Effect of valve type on cerebrospinal fluid shunt efficacy. J Neurosurg Pediatr 2014; 14 Suppl 1:35-43. [PMID: 25988781 DOI: 10.3171/2014.7.peds14325] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The objective of this systematic review was to examine the existing literature to compare differing shunt components used to treat hydrocephalus in children, find whether there is a superior shunt design for the treatment of pediatric hydrocephalus, and make evidence-based recommendations for the selection of shunt implants when placing shunts. METHODS Both the US National Library of Medicine PubMed/MEDLINE database and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words chosen to identify publications comparing the use of shunt implant components. Abstracts of these publications were reviewed, after which studies meeting the inclusion criteria were selected. An evidentiary table was compiled summarizing the selected articles and quality of evidence. These data were then analyzed by the Pediatric Hydrocephalus Systematic Review and Evidence-Based Guidelines Task Force to consider evidence-based treatment recommendations. RESULTS Two hundred sixty-nine articles were identified using the search parameters, and 43 articles were recalled for full-text review. Of these, 22 papers met the study criteria for a comparison of shunt components and were included in the evidentiary table. The included studies consisted of 1 Class I study, 11 Class II studies, and 10 Class III studies. The remaining 21 articles were excluded. CONCLUSIONS An analysis of the evidence did not demonstrate a clear advantage for any specific shunt component, mechanism, or valve design over another. RECOMMENDATION There is insufficient evidence to demonstrate an advantage for one shunt hardware design over another in the treatment of pediatric hydrocephalus. Current designs described in the evidentiary tables are all treatment options. STRENGTH OF RECOMMENDATION Level I, high degree of clinical certainty. RECOMMENDATION There is insufficient evidence to recommend the use of a programmable valve versus a nonprogrammable valve. Programmable and nonprogrammable valves are both options for the treatment of pediatric hydrocephalus. STRENGTH OF RECOMMENDATION Level II, moderate degree of clinical certainty.
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Affiliation(s)
| | - Catherine A Mazzola
- Division of Pediatric Neurological Surgery, Goryeb Children's Hospital, Morristown, New Jersey
| | - Kurtis I Auguste
- Department of Neurosurgery, University of California, San Francisco, California
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center,6Le Bonheur Children's Hospital, Memphis, Tennessee; and
| | - Ann Marie Flannery
- Department of Neurological Surgery, Saint Louis University, St. Louis, Missouri
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Lee L, King NKK, Kumar D, Ng YP, Rao J, Ng H, Lee KK, Wang E, Ng I. Use of programmable versus nonprogrammable shunts in the management of hydrocephalus secondary to aneurysmal subarachnoid hemorrhage: a retrospective study with cost-benefit analysis. J Neurosurg 2014; 121:899-903. [DOI: 10.3171/2014.3.jns131088] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The choice of programmable or nonprogrammable shunts for the management of hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH) remains undefined. Variable intracranial pressures make optimal management difficult. Programmable shunts have been shown to reduce problems with drainage, but at 3 times the cost of nonprogrammable shunts.
Methods
All patients who underwent insertion of a ventriculoperitoneal shunt for hydrocephalus after aneurysmal SAH between 2006 and 2012 were included. Patients were divided into those in whom nonprogrammable shunts and those in whom programmable shunts were inserted. The rates of shunt revisions, the reasons for adjustments of shunt settings in patients with programmable devices, and the effectiveness of the adjustments were analyzed. A cost-benefit analysis was also conducted to determine if the overall cost for programmable shunts was more than for nonprogrammable shunts.
Results
Ninety-four patients underwent insertion of shunts for hydrocephalus secondary to SAH. In 37 of these patients, nonprogrammable shunts were inserted, whereas in 57 programmable shunts were inserted. Four (7%) of 57 patients with programmable devices underwent shunt revision, whereas 8 (21.6%) of 37 patients with nonprogrammable shunts underwent shunt revision (p = 0.0413), and 4 of these patients had programmable shunts inserted during shunt revision. In 33 of 57 patients with programmable shunts, adjustments were made. The adjustments were for a trial of functional improvement (n = 21), overdrainage (n = 5), underdrainage (n = 6), or overly sunken skull defect (n = 1). Of these 33 patients, 24 showed neurological improvements (p = 0.012). Cost-benefit analysis showed $646.60 savings (US dollars) per patient if programmable shunts were used, because the cost of shunt revision is a lot higher than the cost of the shunt.
Conclusions
The rate of shunt revision is lower in patients with programmable devices, and these are therefore more cost-effective. In addition, the shunt adjustments made for patients with programmable devices also resulted in better neurological outcomes.
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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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Xu H, Wang ZX, Liu F, Tan GW, Zhu HW, Chen DH. Programmable shunt valves for the treatment of hydrocephalus: a systematic review. Eur J Paediatr Neurol 2013; 17:454-61. [PMID: 23830575 DOI: 10.1016/j.ejpn.2013.04.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2012] [Revised: 04/03/2013] [Accepted: 04/07/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the clinical effectiveness of programmable valves compared with non-programmable valves of hydrocephalus. METHODS In this paper, the authors report a systematic review and meta-analysis of complications and revision rate for programmable valves and non-programmable implantation. Randomized or non-randomized controlled trials of hydrocephalus treated by programmable and non-programmable valves were considered for inclusion. RESULTS Seven published reports of eligible studies involving 1702 participants meet the inclusion criteria. Compared with non-programmable, programmable valves had no significant difference in catheter-related complications [RR = 0.88, 95%CI (0.66,1.19), p = 0.10] and infection rate [RR = 1.25, 95%CI (0.92,1.69), p = 1.00]. There were significant differences in overall complications [RR = 0.80, 95%CI (0.67,0.96), p < 0.01], over-drainage or under-drainage complications [RR = 0.44, 95%CI (0.31,0.63), p < 0.01] and revision rate [RR = 0.56, 95%CI (0.45,0.69), p < 0.01] in favor of programmable valves. CONCLUSION Although the studies seem to demonstrate a small advantage for the programmable shunts, the probable bias and the difficulties in patient selection are too important to make a general conclusion.
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Affiliation(s)
- H Xu
- Department of Neurosurgery, Anhui Provincial Hospital, Hefei, Anhui Province 230001, China
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Hatlen TJ, Shurtleff DB, Loeser JD, Ojemann JG, Avellino AM, Ellenbogen RG. Nonprogrammable and programmable cerebrospinal fluid shunt valves: a 5-year study. J Neurosurg Pediatr 2012; 9:462-7. [PMID: 22546022 DOI: 10.3171/2012.1.peds10482] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Programmable valves (PVs) for shunting CSF have increasingly replaced nonprogrammable valves (NPVs). There have been only a few longer-term studies (≥ 5 years) conducted that have compared the effectiveness of NPVs with that of PVs for children with hydrocephalus, and only 1 study has reported NPVs as being favorable over PVs. The objective of this retrospective study was to compare the long-term survival of these 2 types of shunt valves. METHODS The authors collected data for all patients who underwent CSF shunt insertion or revision between January 1, 2000, and December 31, 2008. Patients underwent follow-up for a minimum of 2 years postoperatively. Statistical analyses were done using chi-square, Kaplan-Meier survival curve, and multivariate analyses. RESULTS A total of 616 valves were implanted, of which 313 were PVs and 303 were NPVs. Of these, 253 were original shunt implantations and 363 were revisions. The proportion of 5-year survival for NPVs (45.8%) was significantly higher than that for PVs (19.8%) (p = 0.0005, log-rank). The NPVs that survived longer than 6 months also survived through the 5th year better than the PVs (p = 0.0001). CONCLUSIONS The authors' data suggest that NPVs survive longer than PVs in children, but there is a need for prospective, case-control studies to confirm these data.
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Affiliation(s)
- Timothy J Hatlen
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
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Kramer K, McCrea HJ, Fischer C, Greenfield JP. Establishing successful cerebrospinal fluid flow for radioimmunotherapy. J Neurosurg Pediatr 2012; 9:316-9. [PMID: 22380961 DOI: 10.3171/2011.12.peds11433] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Successful delivery of intraventricular radioimmunotherapy is contingent on adequate CSF flow. The authors present a patient with medulloblastoma in whom obstructed CSF flow was causing hydrocephalus, which was initially corrected by implantation of a programmable shunting device. While managing the hydrocephalus, an endoscopic third ventriculostomy (ETV) needed to be performed in a collapsed ventricular system to ensure adequate radioimmunotherapy distribution. This 18-month-old patient with medulloblastoma involving leptomeningeal dissemination presented for intraventricular radioimmunotherapy. A CSF (111)In-DTPA scintigraphy study obtained through the existing programmable ventriculoperitoneal shunt demonstrated activity in the lateral and third ventricles, but no activity over the cerebral convexities or spinal canal, consistent with obstruction at the level of the cerebral aqueduct. By maximization of ventricular size in a controlled setting, the patient was able to undergo a trial of ETV through very small ventricles. A postoperative CINE MR imaging study confirmed patent ETV. The pressure settings on the shunt were kept at the highest opening pressure (200 mm H(2)O) to maximize flow through the stoma and improve the distribution of CSF throughout the subarachnoid space. The CSF flow scintigraphy study was again performed, this time with tracer activity demonstrated down the thecal sac at 3 hours, and symmetrically over the cerebral convexities at 24 hours. The patient began weekly intraventricular administration of (131)I-3F8 therapy. Successful rerouting of CSF flow for the purpose of therapeutic radioisotope administration is possible. Endoscopic third ventriculostomy can be considered in patients with programmable shunting devices; normal or slit ventricles do not preclude successful ETV.
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Affiliation(s)
- Kim Kramer
- Department of Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA.
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Mauer UM, Kunz U. More malfunctioning Medos Hakim programmable valves: cause for concern? J Neurosurg 2011; 115:1047-52. [DOI: 10.3171/2011.5.jns101396] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
In recent years, the authors have noticed a growing number of programmable valve defects at their institution. Therefore, they conducted this study to evaluate the increased incidence of malfunctioning valves.
Methods
They investigated all revisions that had been performed at their institution between 1994 and 2010 for dislodgement of the stator of a standard Medos Hakim programmable valve with a prechamber.
Results
Fifteen valves were removed because of dislodged stators. The valves had been implanted between May 16, 1993, and December 27, 2002, and were explanted between February 19, 2006, and January 22, 2010. Thus, the valves had been in place for a mean period of 11 years (median 11 years, range 7–14 years). The percentage of dislodged stators was almost 3% (15 of 546 valves). Particularly noteworthy is that all malfunctioning valves were found in children who had been younger than 1 year of age at the time of implantation.
Conclusions
Medos Hakim programmable valve malfunctions are rare events but should receive careful attention. When the pressure setting cannot be adjusted, a malfunction should always be suspected and radiographic imaging should be performed to assess the valve. Stator dislodgement is the most serious form of valve adjustment failure.
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Sprung C, Schlosser HG, Lemcke J, Meier U, Messing-Jünger M, Trost HA, Weber F, Schul C, Rohde V, Ludwig HC, Höpfner J, Sepehrnia A, Mirzayan MJ, Krauss JK. The Adjustable proGAV Shunt. Neurosurgery 2010; 66:465-74. [DOI: 10.1227/01.neu.0000365272.77634.6b] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
To evaluate the reliability of the gravitation-assisted adjustable proGAV shunt system with a prospective multicenter study conducted in 10 German hospitals.
METHODS
Enrollment for this observational study began in April 2005 and concluded in February 2006. The protocol required re-examinations 3 and 6 months postoperatively and fixed the endpoint of follow-up at 12 months after implantation. Patients with different types of adult, juvenile, and pediatric hydrocephalus were included and 165 patients were enrolled; 9 died and 12 had incomplete follow-up.
RESULTS
Of the assessable 144 patients, 130 completed the protocol after 12 months, whereas 14 failed because of the need to explant the device, mainly because of infection. In 12 patients, components of the shunt, not the valve, were revised. In 65 of the 144 patients, there were 102 readjustments of the valve in 67 incidences because of underdrainage and in 35 because of overdrainage. In 1 case, readjustment was not possible. Determination of pressure level with the verification instrument was safe and corresponded to the required x-ray controls after adjustments. No unintended readjustments were noted.
CONCLUSION
The proGAV is a safe and reliable device.
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Affiliation(s)
- Christian Sprung
- Department of Neurosurgery, Universitätsmedizin Berlin–Charité, Berlin, Germany
| | | | - Johannes Lemcke
- Department of Neurosurgery, Unfallkrankenhaus, Berlin, Germany
| | - Ullrich Meier
- Department of Neurosurgery, Unfallkrankenhaus, Berlin, Germany
| | - Martina Messing-Jünger
- Department of Paediatric Neurosurgery, Asklepios Children Hospital Sankt Augustin, Bonn, Germany
| | - Hans Axel Trost
- Department of Neurosurgery, Bogenhausen Hospital, München, Germany
| | | | - Christoph Schul
- Department of Neurosurgery, University of Münster, Münster, Germany
| | - Veit Rohde
- Department of Neurosurgery, University of Göttingen, Göttingen, Germany
| | | | - Jürgen Höpfner
- Department of Neurosurgery, Kassel Hospital, Kassel, Germany
| | | | - M. Javad Mirzayan
- Department of Neurosurgery, Medical School Hannover, Hannover, Germany
| | - Joachim K. Krauss
- Department of Neurosurgery, Medical School Hannover, Hannover, Germany
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Gruber RW, Roehrig B. Prevention of ventricular catheter obstruction and slit ventricle syndrome by the prophylactic use of the Integra antisiphon device in shunt therapy for pediatric hypertensive hydrocephalus: a 25-year follow-up study. J Neurosurg Pediatr 2010; 5:4-16. [PMID: 20043731 DOI: 10.3171/2008.7.17690] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT This 25-year follow-up study was performed on 120 children with hypertensive hydrocephalus to evaluate the influence of the early prophylactic implantation of the Integra antisiphon device (ASD, Integra Neurosciences Ltd.) on the rate of proximal shunt obstructions and the frequency of symptomatic slit ventricle syndrome (SVS). The adaptability of the ASD to growth, proper positioning of the ASD as a necessity for its successful performance, and the 3 phases of SVS development are discussed. METHOD Since 1978, the ASD has consistently been implanted either at the time of primary shunt insertion (66 neonates, mean follow-up 11 years) or during revisions of preexisting shunts (54 children, mean follow-up 11.8 years). The complication rate among the 54 children before ASD implantation (mean follow-up 8.3 years) was compared with that among all 120 patients once an ASD had been inserted. Shunt complications were documented as ventricular catheter, distal catheter, and infectious complications. RESULTS The study revealed a significant long-term reduction in ventricular catheter obstructions and hospitalizations due to intermittent intracranial hypertension symptoms (symptomatic SVS) after both primary and secondary ASD implantation. Data in the study suggest that the high rate of ventricular catheter obstruction in pediatric shunt therapy is caused by hydrostatic suction induced by differential-pressure valve shunts during mobilization of the patient and that the development of a SVS can be traced back to this constant suction, which causes chronic CSF overdrainage and ventricular noncompliance. Recurrent ventricular catheter obstruction and SVS can be prevented by prophylactic supplementation of every shunt system with an ASD. CONCLUSIONS To inhibit chronic hydrostatic suction, to prevent overdrainage and proximal shunt obstruction, and to avoid SVS and thus improve the patient's quality of life, the prophylactic implantation of an ASD in every pediatric hydrocephalus shunt is recommended.
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Affiliation(s)
- Rolf W Gruber
- Pediatric Surgery Department, Klinikum Mutterhaus, Trier, Germany.
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18
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Arnell K, Koskinen LOD, Malm J, Eklund A. Evaluation of Strata NSC and Codman Hakim adjustable cerebrospinal fluid shunts and their corresponding antisiphon devices. J Neurosurg Pediatr 2009; 3:166-72. [PMID: 19338461 DOI: 10.3171/2008.10.peds08118] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors investigated and compared the in vitro characteristics of 2 CSF shunts, the Strata NSC and the Codman Hakim, and their corresponding antisiphon devices (ASDs). METHODS Six new CSF shunts and the corresponding ASDs for each model were tested in an automated, computerized experimental setup based on pressure regulation. Opening pressure accuracy, resistance, sensitivity to abdominal pressure, antisiphon effect, and the influence of different ASD positions were determined. RESULTS In general the shunts performed according to the manufacturers' specifications. However, at the lowest setting, the opening pressure of the Strata NSC was close to 0, and in the Codman Hakim shunt, it was higher than specified. The resistance in the Codman Hakim shunt (5.4 mm Hg/ml/min) was much higher than that in the Strata NSC (3.6 mm Hg/ml/min). Abdominal pressure affected opening pressure in both valves. Positioning the Strata ASD above or below the ventricular catheter tip resulted in higher and lower opening pressures, respectively, than when it was placed in line with the catheter. The positioning of the Codman Hakim ASD did not influence the opening pressure. CONCLUSIONS Both CSF shunts work properly, but at the lowest setting the opening pressure of the Strata NSC was near 0 and in the Codman Hakim it was twice the manufacturer's specifications. The resistance in the Strata NSC was below the normal physiological range, and in the Codman Hakim device it was in the lower range of normal. The ASD did not change the shunt characteristics in the lying position and therefore might not do so in children. If this is the case, then a shunt system with an integrated ASD could be implanted at the first shunt insertion, thus avoiding a second operation and the possibility of infection.
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Affiliation(s)
- Kai Arnell
- Department of Paediatric Surgery, University Hospital, Uppsala, Sweden.
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Management of neonatal hydrocephalus: feasibility of use and safety of two programmable (Sophy and Polaris) valves. Childs Nerv Syst 2008; 24:549-56. [PMID: 17924120 DOI: 10.1007/s00381-007-0512-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Neonates represent a unique group of pediatric patients with special peculiarities. Hydrocephalus valves have not always been designed to meet the requirements of these small children. Few series have addressed the problem of cerebrospinal fluid shunting in newborn babies. OBJECTIVES We aimed (1) to evaluate the feasibility of the use of two programmable valves (Sophy and Polaris) in hydrocephalic neonates and (2) to ascertain complications and safety issues arising from their use. MATERIALS AND METHODS We performed a prospective study of 100 consecutive preterm and term babies (<2 months of age) given a programmable valve. Valves' settings were readjusted at different pressure levels as required. Outcomes were obtained from the records of our Outpatient Clinic. RESULTS The study group was formed by 60 term and 40 preterm infants (average weight 2,440 g, mean age of 25 days). Mean follow-up was 55 months. Only one fifth deaths was shunt-related. In 70 babies, no complications occurred, and hydrocephalus was successfully controlled. Proximal catheter obstruction presented in 20% and infection in 5% of cases. Several external adjustments of the valves apparently avoided several surgical shunt revisions. CONCLUSIONS (1) Both programmable valves (Sophy and Polaris) can be safely used for treatment of neonatal hydrocephalus, introducing some technical modifications. (2) Both valves are comparable to other shunts with regard to indications, performance, and safety. (3) The possibility of modifying their working pressure seems to constitute their main advantage. Prevention of late overdrainage syndromes with these valves needs a longer follow-up.
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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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21
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Mauer UM, Schuler J, Kunz U. The Hakim programmable valve: reasons for reprogramming failures. J Neurosurg 2007; 107:788-91. [DOI: 10.3171/jns-07/10/0788] [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
In patients with hydrocephalus, the pressure settings of a Medos Hakim programmable valve may require adjustments even months after implantation. In some cases, however, adjustment proves to be impossible. The object of this study was to illuminate the reasons for reprogramming failures.
Methods
Data pertaining to the authors' experience with programmable valves at their clinic were obtained through retrospective review of patient records from 1992 to 1998 and prospectively collected from 1998 to 2006. Between 1992 and 2006, 585 Medos Hakim programmable valves were implanted at the authors' center, and reprogramming failure was observed in 12 of these 585 cases. The authors investigated and recorded the reasons for reprogramming failure. In cases in which the valves had to be explanted, the valves were returned to the manufacturer for further investigation and the results were recorded.
Results
In three of the 12 cases of reprogramming failure, the pressure settings could eventually be adjusted by placing the transmitter upside down against the flow direction. In the remaining nine cases, the valve had to be removed, yielding a rate of valve explantation of approximately 1.5% in this series. In two of these nine cases, the valve was found to be rotated longitudinally along its axis. In two cases the ratchet wheel had become loose and in one the radiopaque marker had become dislodged from the baseplate. Extensive deposits were identified macroscopically and microscopically within four explanted valves.
Conclusions
The reasons for failed reprogramming of Codman Medos Hakim valves as described in this article have not been mentioned in the literature so far. Failure of adjusting the pressure setting is a very rare event in a Medos Hakim programmable valve. The programming and adjustment mechanism appears to be very reliable. Valve replacement was required due to failed reprogramming in only a few cases.
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