An Update on Programmable CSF Shunt Valves: Identification, MR Imaging Safety and Potential Pitfalls

Neurographics ◽  
2020 ◽  
Vol 10 (1) ◽  
pp. 26-32
Author(s):  
J.E. Costello ◽  
U.A. Rassner
Keyword(s):  
Mr Imaging ◽  
Valve Replacement ◽  
Shunt Revision ◽  
Csf Shunt ◽  
Shunt Valve ◽  
Radiographic Appearance ◽  
Csf Drainage ◽  
Valve Function ◽  
Programmable Devices ◽  
Potential Interactions

Programmable shunt valves are commonly used devices for the treatment of hydrocephalus. Unlike fixed shunt valves, programmable devices allow the operator to alter the amount of CSF drainage without the need for shunt revision or valve replacement. With their increased use, many different programmable shunt valves have been developed by various manufacturers; each programmable shunt valve has a distinct radiographic appearance and CSF drainage setting. Because of potential interactions with MR imaging scanners, which can alter programmable shunt valve function, understanding and accurately reporting these devices is essential.Learning Objectives: Identify commonly used programmable shunt valves and understand their CSF drainage settings to enable the detection of device alterations after MR imaging scanning.

scholarly journals Reconsidering Ventriculoperitoneal Shunt Surgery and Postoperative Shunt Valve Pressure Adjustment: Our Approaches Learned From Past Challenges and Failures

2022 ◽  
Vol 12 ◽  
Author(s):  
Shigeki Yamada ◽  
Masatsune Ishikawa ◽  
Madoka Nakajima ◽  
Kazuhiko Nozaki
Keyword(s):  
Ventriculoperitoneal Shunt ◽  
Early Period ◽  
Csf Shunt ◽  
Symptom Improvement ◽  
Shunt Surgery ◽  
Shunt Valve ◽  
Improvement Rate ◽  
Shunt Implantation ◽  
Csf Drainage ◽  
Valve Pressure

Treatment for idiopathic normal pressure hydrocephalus (iNPH) continues to develop. Although ventriculoperitoneal shunt surgery has a long history and is one of the most established neurosurgeries, in the 1970s, the improvement rate of iNPH triad symptoms was poor and the risks related to shunt implantation were high. This led experts to question the surgical indication for iNPH and, over the next 20 years, cerebrospinal fluid (CSF) shunt surgery for iNPH fell out of favor and was rarely performed. However, the development of programmable-pressure shunt valve devices has reduced the major complications associated with the CSF drainage volume and appears to have increased shunt effectiveness. In addition, the development of support devices for the placement of ventricular catheters including preoperative virtual simulation and navigation systems has increased the certainty of ventriculoperitoneal shunt surgery. Secure shunt implantation is the most important prognostic indicator, but ensuring optimal initial valve pressure is also important. Since over-drainage is most likely to occur in the month after shunting, it is generally believed that a high initial setting of shunt valve pressure is the safest option. However, this does not always result in sufficient improvement of the symptoms in the early period after shunting. In fact, evidence suggests that setting the optimal valve pressure early after shunting may cause symptoms to improve earlier. This leads to improved quality of life and better long-term independent living expectations. However, in iNPH patients, the remaining symptoms may worsen again after several years, even when there is initial improvement due to setting the optimal valve pressure early after shunting. Because of the possibility of insufficient CSF drainage, the valve pressure should be reduced by one step (2–4 cmH2O) after 6 months to a year after shunting to maximize symptom improvement. After the valve pressure is reduced, a head CT scan is advised a month later.

Reliability of the radiopharmaceutical shunt flow study for the detection of a CSF shunt malfunction in the presence of stable ventricular size

2020 ◽  
Vol 26 (4) ◽  
pp. 364-370
Author(s):  
Jeffrey J. Quezada ◽  
J. Gordon McComb
Keyword(s):  
Ct Scan ◽  
Operative Intervention ◽  
Shunt Malfunction ◽  
Shunt Revision ◽  
Csf Shunt ◽  
Technical Failure ◽  
Ventricular Size ◽  
Shunt Flow ◽  
Programmable Valve ◽  
Flow Study

OBJECTIVEThe authors sought to determine the reliability of a radiopharmaceutical (RP) shunt flow study for the detection of a CSF-diverting shunt malfunction in the presence of stable ventricular size.METHODSAfter the authors obtained IRB approval, all CSF RP shunt flow studies done between January 1, 2014, and January 1, 2019, in pediatric patients at Children’s Hospital Los Angeles were identified. Included in the study were only those patients in whom an MRI or CT scan was done during the hospital admission for shunt malfunction and showed no increase in ventricular size compared with the most recent prior MRI or CT scan when the patient was asymptomatic. Data recorded for analysis were patient age and sex, etiology of the hydrocephalus, shunt distal site, nonprogrammable versus programmable valve, operative findings if the shunt was revised, and follow-up findings for a minimum of 90 days after admission. The RP shunt flow study consisted of tapping the reservoir and injecting technetium-99m DTPA according to a set protocol.RESULTSThe authors identified 146 RP flow studies performed in 119 patients meeting the above criteria. Four of the 146 RP studies (3%) were nondiagnostic secondary to technical failure and were excluded from statistical analysis. Of the 112 normal flow studies, operative intervention was not undertaken in 102 (91%). The 10 (9%) remaining normal studies were performed in patients who underwent operative intervention, in which 8 patients had a proximal obstruction, 1 had a distal obstruction, and 1 patient had no obstruction. Of the 30 patients with abnormal flow studies, symptoms of shunt malfunction subsided in 9 (30%) patients and these patients did not undergo operative intervention. Of the 21 (70%) operated patients, obstruction was proximal in 9 patients and distal in 5, and for 7 patients the shunt tubing was either fractured or disconnected. Regression analysis indicated a significant association between the flow study interpretation and the odds for shunt revision (OR 27, 95% CI 10–75, p < 0.0001). No other clinical variables were significant. The sensitivity of a shunt flow study alone for detection of shunt malfunction in cases with stable ventricular size was the same as a shunt flow study plus an MRI or CT (70% vs 70%), but performing a shunt flow in addition to MRI or CT did increase the specificity from 92% to 100% and the accuracy from 87% to 94%.CONCLUSIONSRP shunt flow studies were of definite value in deciding whether to operatively intervene in patients with symptoms of shunt malfunction in whom no change in ventricular size was detected on current MRI or CT scans compared to scans obtained when the patients were asymptomatic.

scholarly journals Cerebrospinal fluid biomarkers of neuroinflammation in children with hydrocephalus and shunt malfunction

2021 ◽  
Vol 18 (1) ◽  
Author(s):  
Carolyn A. Harris ◽  
Diego M. Morales ◽  
Rooshan Arshad ◽  
James P. McAllister ◽  
David D. Limbrick
Keyword(s):  
Cerebrospinal Fluid ◽  
Inflammatory Cytokines ◽  
Protein Concentration ◽  
Shunt Revision ◽  
Csf Shunt ◽  
Shunt Failure ◽  
Revision Operation ◽  
Protein Levels ◽  
Anti Inflammatory ◽  
Pro Inflammatory Cytokines

Abstract Background Approximately 30% of cerebrospinal fluid (CSF) shunt systems for hydrocephalus fail within the first year and 98% of all patients will have shunt failure in their lifetime. Obstruction remains the most common reason for shunt failure. Previous evidence suggests elevated pro-inflammatory cytokines in CSF are associated with worsening clinical outcomes in neuroinflammatory diseases. The aim of this study was to determine whether cytokines and matrix metalloproteinases (MMPs) contribute towards shunt failure in hydrocephalus. Methods Using multiplex ELISA, this study examined shunt failure through the CSF protein concentration profiles of select pro-inflammatory and anti-inflammatory cytokines, as well as select MMPs. Interdependencies such as the past number of previous revisions, length of time implanted, patient age, and obstruction or non-obstruction revision were examined. The pro-inflammatory cytokines were IL-1β, IL-2, IL-5, IL-6, IL-8, IL-12, IL-17, TNF-α, GM-CSF, IFN-γ. The anti-inflammatory cytokines were IL-4 and IL-10, and the MMPs were MMP-2, MMP-3, MMP-7, MMP-9. Protein concentration is reported as pg/mL for each analyte. Results Patient CSF was obtained at the time of shunt revision operation; all pediatric (< 18), totaling n = 38. IL-10, IL-6, IL-8 and MMP-7 demonstrated significantly increased concentrations in patient CSF for the non-obstructed subgroup. Etiological examination revealed IL-6 was increased in both obstructed and non-obstructed cases for PHH and congenital hydrocephalic patients, while IL-8 was higher only in PHH patients. In terms of number of past revisions, IL-10, IL-6, IL-8, MMP-7 and MMP-9 progressively increased from zero to two past revisions and then remained low for subsequent revisions. This presentation was notably absent in the obstruction subgroup. Shunts implanted for three months or less showed significantly increased concentrations of IL-6, IL-8, and MMP-7 in the obstruction subgroup. Lastly, only patients aged six months or less presented with significantly increased concentration of IL-8 and MMP-7. Conclusion Non-obstructive cases are reported here to accompany significantly higher CSF cytokine and MMP protein levels compared to obstructive cases for IL-10, IL-6, IL-8, MMP-7 and MMP-9. A closer examination of the definition of obstruction and the role neuroinflammation plays in creating shunt obstruction in hydrocephalic patients is suggested.

scholarly journals Use of a Sandwich Technique to Repair a Left Ventricular Rupture after Mitral Valve Replacement

2014 ◽  
Vol 41 (2) ◽  
pp. 195-197 ◽  
Author(s):  
Myles E. Lee ◽  
Mallika Tamboli ◽  
Anthony W. Lee
Keyword(s):  
Mitral Valve ◽  
Valve Replacement ◽  
Mitral Valve Replacement ◽  
Left Ventricular ◽  
Left Ventricular Aneurysm ◽  
Sandwich Technique ◽  
Ventricular Rupture ◽  
Left Ventricular Rupture ◽  
Valve Function ◽  
Normal Mitral Valve

One difficulty with external repair of left ventricular rupture after mitral valve replacement is collateral bleeding in friable myocardium adjacent to the rupture. The bleeding is caused by tension on the closing sutures, whether or not pledgets have been used. We report the case of a 69-year-old woman who underwent an uneventful mitral valve replacement. After cardiopulmonary bypass was terminated, brisk bleeding started from high in the posterior left ventricular wall, typical of a type III defect. We undertook external repair, placing a plug of Teflon felt into the cavity of the rupture and sandwiching it into place with pledgeted mattress and figure-of-8 sutures. The space occupied by the plug decreased the distance needed to obliterate the defect and thereby reduced the tension on the sutures necessary to achieve hemostasis. This simple technique enabled closure of the defect and avoided collateral tears that would have compromised an otherwise successful repair. Two years postoperatively, the patient had normal mitral valve function and no left ventricular aneurysm. In addition to reporting the patient's case, we review the types of left ventricular rupture that can occur during mitral valve replacement and discuss the various repair options.

In vitro experiment for verification of the tandem shunt valve system: a novel method for treating hydrocephalus by flexibly controlling cerebrospinal fluid flow and intracranial pressure

2013 ◽  
Vol 11 (1) ◽  
pp. 43-47
Author(s):  
Yasuo Aihara ◽  
Ichiro Shoji ◽  
Yoshikazu Okada
Keyword(s):  
Intracranial Pressure ◽  
Flow Rate ◽  
Csf Shunt ◽  
Main Function ◽  
Csf Flow ◽  
Shunt Valve ◽  
Cerebrospinal Fluid Flow ◽  
Valve System ◽  
Programmable Valve

Object The CSF shunt valve is a medical device whose main function is to regulate intracranial pressure and drain excess CSF. The authors have developed a new therapeutic method for treating hydrocephalus, namely the tandem shunt valve system, which has the potential of flexibly controlling the CSF flow rate and intracranial pressure in patients. Methods The properties of the tandem system were verified by performing in vitro experiments. An in vitro system with a manometer was built to measure pressure and flow rates of water in open systems using the Codman Hakim Programmable Valve and the Strata adjustable pressure programmable valve. A single valve and 2 single shunt valves connected in series (the tandem shunt valve system) were connected to the manometer to check the final pressure. Results Conventional single shunt valve systems require valve pressures to be set higher to slow down the CSF flow rate, which inevitably results in a higher final pressure. On the other hand, the tandem shunt valve system uses the combination of 2 valves to slow the CSF flow rate without increasing the final pressure. Conclusions The authors succeeded in experimentally demonstrating in vitro results of tandem systems and their effectiveness by applying a model to show that the valve with the higher pressure setting determined the final pressure of the entire system and the flow rate became slower than single shunt valve systems.

Transesophageal Echocardiography-Guided Ventriculoatrial Shunt Insertion

2019 ◽  
Vol 19 (1) ◽  
pp. 25-31
Author(s):  
Albert McAnsah Isaacs ◽  
Danae Krahn ◽  
Andrew M Walker ◽  
Heather Hurdle ◽  
Mark G Hamilton
Keyword(s):  
Transesophageal Echocardiography ◽  
Perioperative Complications ◽  
Superior Vena ◽  
Vena Cava ◽  
Shunt Revision ◽  
Shunt Valve ◽  
Shunt Insertion ◽  
Distal Catheter ◽  
Shunt Placement ◽  
Time Required

Abstract BACKGROUND Determining an optimal location within the right atrium (RA) for placement of the distal ventriculoatrial (VA) shunt catheter offer several operative challenges that place patients at risk for perioperative complications and downstream VA shunt failure. Utilizing transesophageal echocardiography (TEE) guidance to place distal VA shunt catheters may help to circumvent these risks. OBJECTIVE To review our current practice of VA shunt insertion using TEE guidance. METHODS A retrospective review of all consecutive patients who underwent VA shunt procedures between December 19, 2016 and January 22, 2019, during which time intraoperative TEE was used for shunt placement was performed. Data on the time required for shunt placement and total procedure time, baseline echocardiography findings, and short- and long-term complications of shunt placement were assessed. RESULTS A total of 33 patients underwent VA shunt procedures, with a median follow-up time of 250 (88-412) d. The only immediate complication related to shunt placement or TEE use was transient ectopy in 1 patient. The mean time for atrial catheter insertion was 12.6 ± 4.8 min. Right-heart catheters were inserted between the RA-superior vena cava junction and 22 mm within the RA in all but 3 procedures. A total of 7/33 patients (21%) underwent shunt revision. Indications for revisions included distal clots, proximal obstruction, positive blood culture, and shunt valve revision. No other complications of VA shunt insertion were reported. CONCLUSION VA shunt insertion using TEE allows for precise distal catheter placement. Early patient experience confirms this technique has a low complication rate.

Cerebrospinal fluid edema associated with shunt obstruction

1994 ◽  
Vol 81 (2) ◽  
pp. 179-183 ◽  
Author(s):  
Hiroaki Sakamoto ◽  
Ken Fujitani ◽  
Shouhei Kitano ◽  
Keiji Murata ◽  
Akira Hakuba
Keyword(s):  
Cerebrospinal Fluid ◽  
Subcortical White Matter ◽  
Shunt Revision ◽  
Csf Shunt ◽  
Limited Area ◽  
Ventricular Catheter ◽  
Small Lesion ◽  
Rapid Improvement ◽  
Content Type ◽  
Shunt Obstruction

✓ The authors report four hydrocephalic children with cerebrospinal fluid (CSF) edema extending along the ventricular catheter of an obstructed CSF shunt. Three of the patients exhibited massive CSF edema along the ventricular catheter, yet they manifested neither ventricular enlargement nor apparent periventricular CSF edema despite increased intraventricular pressure. These findings suggested ventricular tautness. The remaining patient, who had dilated ventricles with periventricular CSF edema, displayed CSF edema in a limited area along the ventricular catheter. Replacement of the obstructed peritoneal catheter of the shunt resulted in rapid improvement of the edema in all patients. In the three patients with massive CSF edema, however, a small lesion remained in the subcortical white matter along the ventricular catheter as demonstrated by computerized tomography and/or magnetic resonance imaging 3 to 5 years after shunt revision. It is concluded that shunt obstruction may result in massive CSF edema along the ventricular catheter in hydrocephalic children who have ventricular tautness after installation of the shunt causing irreversible although usually asymptomatic damage to the affected area of the brain.

Adjustable shunt valve–induced magnetic resonance imaging artifact: a comparative study

2010 ◽  
Vol 113 (1) ◽  
pp. 74-78 ◽  
Author(s):  
Ahmed K. Toma ◽  
Andrew Tarnaris ◽  
Joan P. Grieve ◽  
Laurence D. Watkins ◽  
Neil D. Kitchen
Keyword(s):  
Mr Imaging ◽  
Pulse Sequence ◽  
Spin Echo ◽  
Pulse Sequences ◽  
Fast Spin Echo ◽  
Mr Images ◽  
Shunt Valve ◽  
Adjustable Valve ◽  
Imaging Artifact

Object In this paper, the authors' goal was to compare the artifact induced by implanted (in vivo) adjustable shunt valves in spin echo, diffusion weighted (DW), and gradient echo MR imaging pulse sequences. Methods The MR images obtained in 8 patients with proGAV and 6 patients with Strata II adjustable shunt valves were assessed for artifact areas in different planes as well as the total volume for different pulse sequences. Results Artifacts induced by the Strata II valve were significantly larger than those induced by proGAV valve in spin echo MR imaging pulse sequence (29,761 vs 2450 mm3 on T2-weighted fast spin echo, p = 0.003) and DW images (100,138 vs 38,955 mm3, p = 0.025). Artifacts were more marked on DW MR images than on spin echo pulse sequencse for both valve types. Conclusions Adjustable valve–induced artifacts can conceal brain pathology on MR images. This should influence the choice of valve implantation site and the type of valve used. The effect of artifacts on DW images should be highlighted pending the development of less MR imaging artifact–inducing adjustable shunt valves.

CEREBROSPINAL FLUID DRAINAGE AND DYNAMICS IN THE DIAGNOSIS OF NORMAL PRESSURE HYDROCEPHALUS

Neurosurgery ◽  
2009 ◽  
Vol 64 (5) ◽  
pp. 919-926 ◽  
Author(s):  
Graeme F. Woodworth ◽  
Matthew J. McGirt ◽  
Michael A. Williams ◽  
Daniele Rigamonti
Keyword(s):  
Cerebrospinal Fluid ◽  
Normal Pressure Hydrocephalus ◽  
Normal Pressure ◽  
Waveform Analysis ◽  
Csf Shunt ◽  
Symptom Improvement ◽  
Wave Characteristics ◽  
Csf Drainage ◽  
Ventriculoperitoneal Shunting ◽  
Csf Shunting

Abstract INTRODUCTION Because of the difficulty in distinguishing idiopathic normal pressure hydrocephalus (INPH) from other neurodegenerative conditions unrelated to cerebrospinal fluid (CSF) dynamics, response to CSF shunting remains highly variable. We examined the utility of CSF drainage and CSF pressure (Pcsf) dynamics in predicting response to CSF shunting for patients with INPH. METHODS Fifty-one consecutive INPH patients underwent continuous lumbar Pcsf monitoring for 48 hours followed by 72 hours of slow CSF drainage before ventriculoperitoneal shunting. Response to CSF drainage and B-wave characteristics were assessed via multivariate proportional-hazards regression analysis. RESULTS Improvement in 1, 2, or all 3 INPH symptoms was observed in 35 (69%), 28 (55%), and 11 (22%) patients, respectively, after CSF shunt implantation by 12 months after surgery. A positive response to CSF drainage was found to be an independent predictor of shunt responsiveness (relative risk, 0.30; 95% confidence interval, 0.09–0.98; P = 0.05). There was no difference in Pcsf wave characteristics between the shunt-responsive and -nonresponsive groups, regardless of whether 1-, 2-, or 3-symptom improvement was used to define response to CSF shunting. CONCLUSION In this study of 51 INPH patients who underwent Pcsf monitoring with waveform analysis and CSF drainage followed by shunt surgery, there was no correlation between specific Pcsf wave characteristics and objective symptomatic improvement after shunt placement. Pcsf monitoring with B-wave analysis contributes little to the diagnostic dilemma with INPH patients. Clinical response to continuous CSF drainage over a 72-hour period suggests a high likelihood of shunt responsiveness.

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