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Hydrocephalus and Neuro Shunting. Sales Training April 2001. Hydrocephalus : From the Greek word hydro (water) & cephalo (head). A pathological condition where there is a disturbance in production, circulation and/or absorption of CSF, with subsequent accumulation of CSF

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Hydrocephalus and neuro shunting l.jpg

Hydrocephalus and Neuro Shunting

Sales Training

April 2001


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  • Hydrocephalus:From the Greek

  • word hydro (water) & cephalo (head).

  • A pathological condition where there

  • is a disturbance in production,

  • circulation and/or absorption of CSF,

  • with subsequent accumulation of CSF

  • in the fluid-filled compartments of the

  • brain (ventricles).


About csf cerebrospinal fluid l.jpg
About CSF(Cerebrospinal Fluid)

  • Clear, colorless fluid

  • Bathes, nourishes & protects brain and spinal cord.

  • Average CSF production-20ml/hr adults and 8ml/hr children

  • 400 to 500cc produced daily contains 15 to 45mg/100ml protein,some glucose, salts, urea and WBC’s


Ventricular system l.jpg
Ventricular System

  • Fluid filled cavities deep in cerebrum w/ pressure of 120-180mmH2O

  • Four ventricles

    • 2 Lateral

    • Third

    • Fourth

  • Connected by

    • Foramen of Monro

    • Aqueduct of Sylvius


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Choroid Plexus

Very vascular

Found throughout but mostly in lateral

Responsible for ICP waveform/

follows arterial pulse


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Brain Layers/CSF Absorption

A. - Arachnoid

A.G. - Arachnoid

Granulation

B. - Bone

C.A. - Cerebral Artery

C.V. - Cerebral Vein

D. - Dura Mater

F.C. - Falx Cerebri

P.M. - Pia Mater

S. - Skin

S.A.S. - Sub-Arachnoid

Space

S.D.S. - Sub-Dural Space

S.S.S. - Superior Sagittal

Sinus


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CSF Flow-path

  • CSF flows in a caudal direction through the lateral, third and fourth ventricles

  • Exits through foramina of Luschka and Magendie into subarachnoid space around spinal cord and brain.

  • Absorption occurs through the arachnoid granulations into the venous system.


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Communicating

Non-communicating or Obstructive

Normal Pressure Hydrocephalus

Congenital

Acquired

Types of Hydrocephalus


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CT Scan Showing severe

hydrocephalus

Normal CT Scan


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Etiology of Hydrocephalus

  • Communicating

    • Overproduction/underabsorption of CSF

    • Choroid Plexus Papilloma-overproduces CSF

    • SAH

    • Infection

    • Neoplasms affecting the meninges

    • Trauma


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Etiology of Hydrocephalus

  • Non-Communicating (Obstructive)

    • Aqueductal Stenosis

    • Arnold-Chiari Malformation (Cerebellar tonsils protrude into Foramen Magnum)

    • Cysts

    • Myelomeningocele

    • IVH

    • Tumors (particularly posterior fossa)


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Normal Pressure Hydrocephalus

  • Usually present in elderly

  • Ventricular dilation despite normal CSF pressure

  • Triad of symptoms

  • 1) dementia

  • 2) gait disturbances (usually earliest)

  • 3) urinary incontinence


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Signs & Symptoms Associated with Hydrocephalus

  • Infants

    • Increased head size

    • Bulging Fontanels

    • Separation of Cranial Sutures

    • Prominent Scalp Veins

    • Persistent Vomiting

    • Lethargy or irritability

    • “Setting Sun” eyes

    • Seizures

    • Delayed Development


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S/S Associated with Hydrocephalus, cont.

  • Toddlers

    • Increased head size

    • Persistent vomiting

    • Headache

    • Lethargy or irritability

    • “Setting Sun” eyes

    • Blurred Vision

    • Seizures

    • Delayed Development


Hydrocephalus l.jpg
Hydrocephalus

  • “SETTING SUN” EYES


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S/S Associated with Hydrocephalus, cont.

  • Older Children & Adults

    • Persistent Vomiting

    • Headache**

    • Visual Problems

    • Lethargy

    • Behavior Changes

    • Difficulty with schoolwork

    • Seizures


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Diagnosis

  • Clinical Evaluation

  • Ultrasound (Intrauterine & through Fontanels.

  • CT Scan

  • MRI


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Treatment Modalities

  • Surgical Procedures

    • Remove obstruction (Blood Clots, Tumors)

    • Endoscopic Third Ventriculostomy

    • Septal Fenestrations (Endoscopic)

    • Cyst Fenestrations (Endoscopic)

    • Shunt Insertion


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Interventions for Hydrocephalus

  • If untreated:

  • *50-60% die of complications

  • If treated:

  • *40% normal intelligence

  • *70% live beyond infancy



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Historical Treatment of Hydrocephalous

  • Hippocrates recognizes water accumulation in the brain.

  • 1545-Thomas Phaire-1st non-surgical treatment--Herbal plasters, head wraps

  • 18th Century--ventricular puncture--death from meningitis common

  • 1800’s-Variety of materials used to “wick” CSF from ventricles to subarachnoid space (i.e., linen threads, glass wool, rubber tube)

  • 1898-first lumboperitoneal shunt


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Historical Treatment of Hydrocephalous, con’t

  • 1922-Dandy-third ventriculostomy through subfrontal

  • approach

  • 1923-Mixter-1st endoscopic 3rd Vent., choroid plexectomy

  • (L’Espinasse, Hildebrande, Dandy, Putnam and Scarff)

  • 1950’s-First effective CSF diversion with a one-way valve

  • using biocompatible synthetic materials.

    • John Holter-1st Silicone Valve

    • Robert Pudenz-Silicone distal slit valve

    • Peritoneum chosen as better absorptive site than the

      vascular system


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Heyer Schulte and Shunt Industry History

  • 1953: Dr. Robert Pudenz and W.T. (Ted) Heyer team up on hydrocephalus research

  • 1955: Pudenz ventriculo-atrial shunt is developed

  • 1959: Rudy Schulte joins Heyer and Pudenz

  • 1959: Pudenz flushing valve is developed

  • 1960: Codman distributes Heyer-Schulte products

  • 1960: Holter valve is created

  • 1965: Cordis begins U.S. presence

  • 1965: Extra-Corporeal buys Holter

  • 1973: Codman dropped as Heyer-Schulte distributor


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Heyer Schulte and Shunt Industry History

  • 1974: American Hospital Supply buys Heyer-Schulte

  • 1975: Codman introduces their own product line

  • 1977: Anasco, PR manufacturing facility is built

  • 1978: Codman buys Extra-Corporeal

  • 1983: AHS folds Heyer-Schulte into V. Mueller

  • 1984: Dr. Pudenz and Rudy Schulte found P-S Medical

  • 1986: Baxter-Travenol acquires AHS


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Heyer Schulte and Shunt Industry History

  • The 90’s

    • NeuroCare Group acquires Heyer-Schulte

    • Radionics introduces full shunt line

    • Medtronic acquires P-S Medical

    • Phoenix Biomedical enters the market

    • Codman acquires Cordis

    • Elekta acquires Cordis

    • NMT acquires Cordis

    • Integra acquires Heyer-Schulte


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What is a Shunt?

  • A shunt is a device that diverts CSF from the CNS (usually the lateral ventricle or the lumbar subarachnoid space) to an alternate body cavity (usually the peritoneum or the right atrium) where it is reabsorbed.


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How Shunts Work

  • Divert CSF from the CNS to another body cavity (R atrium, peritoneum) for absorption.

  • Mechanical device that regulates flow out of the ventricle.

  • One-way valve opens when the sum of the forces acting on it exceed some threshold. (the difference between the inlet or ventricular pressure and outlet or peritoneal pressure.


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Shunt Systems

  • Ventriculo-peritoneal

  • Ventriculo-atrial

  • Lumbar-peritoneal


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Shunt Components

  • Primary Components

    • Proximal Catheter

    • Valve (Proximal or Distal)

    • Distal Catheter

  • Optional Components

    • Reservoir

    • Siphon Limiting Mechanism (ASD, SCD, GCD)

  • Accessories

    • Connectors

    • Guides

    • Introducers/Stylets

    • Catheter Passers


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SHUNT ACCESSORIES

  • Proximal catheter stylet (can use endoscope)

  • Stylets for unitized shunts

  • Shunt passers

  • Connectors and Right angle guides

  • Shunt tap kits

  • Manometers


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Valve Mechanisms

  • Differential Pressure Valves

  • Flow regulating devices


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Valve Mechanisms

  • Differential Pressure Valves

  • Valves open when difference between the ventricular pressure and the peritoneal pressure exceeds some threshold.

  • Pressure difference at which a valve opens is called the opening pressure.

  • Pressure difference at which a valve closes is called the closing pressure.


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Valve Types

  • Burr Hole - shaped to fit the hole made in the skull.

  • The reservoir is an integral part e.g. Pudenz

  • Flat Bottom - rests flat against the skull distal to the

  • ventricular catheter e.g. LPV II, Novus

  • Cylindrical/In Line - appears “seamless” between the

  • ventricular and peritoneal catheters

  • e.g.. Ultra VS







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Internal Valve Components

  • Slit

  • Ball and Spring

  • Miter

  • Diaphragm


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Valve Mechanisms

Slit

Miter


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Valve Internal Mechanisms

  • High spring rate valves- open slowly, close quickly (miter, slit)

  • Low spring rate valves- open quickly, close slowly (diaphragm, ball & spring, prone to siphon)


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Valve Mechanisms

  • Slit valves - a slit in a curved rubber layer. The flow arriving from the concave side opens slit, size of opening relating to the upstream pressure

  • Can be proximal or distal

  • Disadvantage:

    • ”stickiness” of silicone rubber can affect opening

    • Precision?

    • Varies with age of valve?


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Slit Valves

  • Codman

    • Holter (proximal catheter/valve)

    • Denver (proximal catheter)

    • Accuflo (distal catheter)

    • Uni-shunt (distal catheter)

  • Radionics

    • Proximal slit valve

  • Phoenix

    • Holter-Hausner valve



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Valve Mechanisms

  • Mitre valves - the leaves of the “duckbill” part in response to the pressure differential. Pressure characteristics of mitre valve are related to size,shape, thickness and length of leaves.

  • Disadvantage :

    • “stickiness” of silicone rubber can affect opening


Mitre valves l.jpg
Mitre Valves

  • Heyer-Schulte

    • Ultra-VS(cylindrical)

    • Mishler Dual Chamber (flat bottom)

    • Spetzler in-line Lumbar - Peritoneal valve (cylindrical)


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Valve Mechanisms

  • Spring valves/Ball in cone - a metallic spring which applies force to a ball (usually ruby or sapphire) located in an orifice. Opening pressure is defined by spring stiffness

  • Disadvantage:

    • prone to obstruction from CSF debris or high protein content

    • subject to siphoning


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Ball-in-Cone Valves

  • Codman Medos Hakim

    • Medos Programmable

  • NMT/Cordis

    • Atlas

    • Hakim

    • Orbis Sigma II

  • Sophysa

    • Sophy Programmable


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Valve Mechanisms

  • Diaphragm valves - a round diaphragm rests on or under a valve seat. Pressure causes the diaphragm to be detracted from the seat allowing CSF to flow

  • Disadvantage:

    • prone to siphoning

    • in some designs flow is not laminar making it prone to obstruction


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Diaphragm Valves

  • Heyer-Schulte

    • Pudenz (burr hole)

    • LPV II (flat bottom)

    • Novus (flat bottom)

  • PS Medical/Medtronic

    • Delta (Burr hole, flat bottom)

    • Button(flat bottom)

    • Contour (flat bottom)


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Diaphragm Valves

  • Radionics

    • Contour Flex

    • Equi-flow

    • Burr hole

  • Codman

    • Accu-flo valve


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Valve Mechanisms

  • Flow regulating mechanisms

  • Maintains same flow rate at any differential pressure by increasing or lowering its resistance to pressure

  • May be achieved by a solid conical cylinder inserted inside a ring attached to a pressure sensitive membrane


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Valve Mechanisms

  • Inner diameter of ring is

  • greater than larger

  • outer diameter of

  • conical cylinder

  • By reducing surface

  • area, mechanism

  • restricts amount of fluid

  • that can go through

  • Outer cylinder moves

  • to compensate for

  • reduced surface area

  • to maintain flow rate.


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Valve Mechanisms

  • At very low pressures acts like a DP valve

  • At high pressures the ring moves beyond the central cylinder to give a “blow off” valve.


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Treatment for Siphoning

  • In a vertical position, negative pressure from hydrostatic column can cause overdrainage

  • Siphoning control achieved by adding siphon resistive devices to the shunt system.

  • Functions as a second valve in line that closes in response to peritoneal pressure


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Shunt Failures and Complications

  • Shunt failure is at a maximum in first few months after surgery (25-40% at one year follow-up). Then falls to 4-5%

  • The mean survival for a shunt is approx 5 years


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Shunt Failures and Complications

  • Shunt obstruction (about 50 - 60% of all failures)

  • Infection(between 5 - 10%)

  • Mechanical failure due to disconnection

  • Valve failure

  • Overdrainage

  • Patient/shunt mismatch


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Shunt Placement Procedure

  • Skin Incision

  • Placement of Burr Hole

  • Sbcutaneous dissection

  • Tunnel the peritoneal catheter

  • Open dura & place ventricular catheter

  • Connect valve, test & clean

  • Distal catheter insertion & skin closure


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Shunt Implantation Approaches

Occipital Approach

Temporal Approach

Frontal Approach


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Metopic

Suture

Coronal

Suture

Anterior

Fontanelle

Sagittal

Suture

Posterior

Fontanelle

Lamboidal

Suture

Adult human skull seen from above

Skull of a newborn seen from above


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Indications For Use of a Lumbar-Peritoneal Shunt

  • Communicating Hydrocephalus - when ventricles are small and it would be difficult to cannulate with a ventricular catheter.

  • Normal Pressure Hydrocephalus - shunting without necessitating a cranial procedure.


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Goals of Shunt Design & Development

  • Restoration of “normal physiology” in the shunted individual

  • Maximize the potential quality of life for each patient

  • Expand the population of successfully treated patients





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Integra NeuroSciencesConsistency by Design


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FLOW PATH

DELTA VALVE


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LPV II Valve Performance

at High Flow Rates (45.8ml/hr)

LPV Valve Performance

at High Flow Rates (45.8ml/hr)


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LPV II Valve Performance

at Low Flow Rates (4.6ml/hr)

LPV Valve Performance

at Low Flow Rates (4.6ml/hr)


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Competitive Matrix

  • Medtronic P.S. Medical

  • Cordis

  • Codman

  • Radionics

  • Sophysa

  • Phoenix






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Product line strengths

  • Consistency and predictability

  • Broad product line

  • Clnical support

  • History

  • Manufacturing expertise

  • Pricing flexibility


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