XIX Congress of the European Society for Pediatric Neurosurgery Rome, May 6-9th 2004 Perspectives of...
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Transcript of XIX Congress of the European Society for Pediatric Neurosurgery Rome, May 6-9th 2004 Perspectives of...
XIX Congress of the European Society for Pediatric Neurosurgery Rome, May 6-9th 2004
Perspectives of the Shunt Technology: iValve and DigiShunt
Aschoff A, Hashemi B, Scheihing M, Unterberg A, Kremer P
University of Heidelberg, Department of Neurosurgerye-mail: [email protected]
Oral presentation on Sunday, May 9th, 2004 Selected slides
Shunt-Revisions: Quantities
Disconnections
Hydraulic Mismanagement
Infections
Misplaced catheters
Ventricular Catheters - Positions Prospective, 63 EVD-catheters
23.4% Anterior horn, ipsilateral
5.8% Lateral ventricle, ipsilateral5.8% Anterior horn, contralateral
19.3% other positions in the ventricles
2.3% extraventricular intrathecal2.3% in the brain parenchymaWeis N, Naff N, Hanley D: Accuracy of intraventricular
catheter placement ... Poster 221, AANS 2/2003 Phoenix
Tolerance for lateral deviations ±3o only!
±3o Catheter,ideal
position=
all holesfree in the ventricle
Current Quotes of Shunt-Infections Valve Patients Procedures
% n % n Pollack 99 Medos P 9.8 377 Kestle 00 OSV,DP,Delta 8.4 367 Zemack 01 Medos P 11.4 477 8.5 660 Lundkvist 01 Medos P 11.0 122 Götz 01 Medos P 2.8 143 Richards 01 multiple *2.6/6.0 12,950 (*Erst-OP) Vougioukas 01 OSV I+II 8.6 81 Kiefer 01 G-valves 1.7 120 Cochrane 02 multiple 8.6 12,106 Hanlo 03 OSV II 8.2 557 Vinchon 03 multiple 21.7 1564 6.6
1. Sterility in theOP-theatre
2. Antibacterial surface modification of implant
3. Systemic antibiotic prophylaxis
55 rabbits, prospective, randomized Ventricular catheter ± Rifampin (covalent) ± 107 Staph. epiderm., 105 Staph. aureus
- Untreated catheters: 96 % Infections of catheters & brain
- Rifampin-catheters:
0 % Infections of implant p<0,001
Kockro, Aschoff et al. J Med Microbiol 49 (2000):441-450
Simple slit- and diaphragm- valves, Orbis-Sigma:
Inaccuracies & long-term-drifts common
ASD, Delta, distal slit ... : Safety deficits
Instable valve bodiesReflux …
Codman-MedosMiethke ProGAVSophysa-Polaris
+ gravitational valve
Adjustable Valves: Change of Technological Leadership ?
Adjustable Valves – Present Use
Treatment of self-produced complications (preferebly overdrainage)
Fine tuning for individual needs
Training to shunt-independence
Psychotherapy
Adjustable Valves and Shunt-Removal
1. Stepwise increase of valve pressure to 200-400 mmH2O 2. Shunt removal after 1/2 - 2 years
In 59% (71/120) successful!
Takahashi Y (2001) Withdrawal of the shunt systems - clinical use of the programmable shunt system and its effcects in hydrocephalus in children. Child´s Nerv Syst 17:472-477
Adjustable Valves – Use in Future
Treatment of self-produced complications
Fine tuning for individual needs
Psychotherapy
Training to shunt-independence
2 13
Ball- + g-valve
G- + adjustable valve
adjustable alone
Gravitational Valves - Problems
- Complicated stock-keeping in OR 6 supplementary devives (e.g. Shunt-Assistant) 6 complete g-valves (e.g. PaediGAV)
- In case of growth, adipositas, pregnancy, or inadequate pressure selection is under- or (residual) overdrainage not excluded.
- No individual fine-tuning
Gravitational Valves - Perspectives
Adjustable g-Valves
Percutaneous variation
- Number of “active“ balls
- Balls with different weights
- Variation of the cone-geometry
Shunt Technology in 2005
1. Adjustable valve 50-350 mmH2O Stable in MRI, X-ray control not necessary
2. + gravitational valve, adjustable between 100-350 mmH2O, stable during jogging etc.
3. + low-flow-catheter (ID Ø 0.8 mm)
4. ICP-telemetry (sensor intradural)
5. Incorporated antibiotics
Shunt Technology in 2010
- 2 intracranial microtransducers - 2 extrathecal transducers - 2 gravitational chip sensors - Storage chip: ICP of last month - Telemetry - Electronically controlled valve - CPU, programmable for an “event- controlled” shunt function and training to shunt-independence