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XIX Congress of the European Society for Pediatric Neurosurgery Rome, May 6-9th 2004

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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

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slide1

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 Selectedslides

slide2

Shunt-Revisions: Quantities

Misplaced catheters

Hydraulic Mismanagement

Infections

Disconnections

slide3

Ventricular Catheters - Positions Prospective, 63 EVD-catheters

23.4% Anterior horn, ipsilateral

5.8% Lateral ventricle, ipsilateral 5.8% Anterior horn, contralateral 19.3% other positions in the ventricles

2.3% extraventricular intrathecal 2.3% in the brain parenchyma

Weis N, Naff N, Hanley D: Accuracy of intraventricular catheter placement ... Poster 221, AANS 2/2003 Phoenix

slide4

±3o

Catheter,ideal position= all holesfree in the ventricle

Tolerance for lateral deviations ±3o only!

slide5

Current Quotes of Shunt-Infections

Valve Patients Procedures % n % n Pollack 99 Medos P 9.8 377 Kestle 00 OSV,DP,Delta8.4 367Zemack 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

slide6

1. Sterility in theOP-theatre

2. Antibacterial surface modification of implant

3. Systemic antibiotic prophylaxis

slide7

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

slide8

Simple slit- and diaphragm- valves, Orbis-Sigma:

Inaccuracies & long-term-drifts common

slide9

ASD, Delta, distal slit ... : Safety deficits

Instable valve bodiesReflux …

slide10

Adjustable Valves: Change of Technological Leadership ?

Miethke ProGAVSophysa-Polaris+ gravitational valve

Codman-Medos

slide11

Adjustable Valves – Present Use

Treatment of self-produced complications (preferebly overdrainage)

Fine tuning for individual needs

Psychotherapy

Training to shunt-independence

slide12

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

slide13

Adjustable Valves – Use in Future

Training to shunt-independence

Fine tuning for individual needs

Psychotherapy

Treatment of self-produced complications

slide14

G- + adjustable valve

adjustable alone

Ball- + g-valve

1

2

3

slide15

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

slide16

Gravitational Valves- Perspectives

Adjustable g-Valves

Percutaneous variation

- Number of “active“ balls

- Balls with different weights

- Variation of the cone-geometry

slide17

Shunt Technology in 2005

1. Adjustable valve 50-350 mmH2OStable 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

slide18

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

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