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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

Hydrocephalus and Neuro Shunting

Sales Training

April 2001

slide2

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
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
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
slide6
Choroid Plexus

Very vascular

Found throughout but mostly in lateral

Responsible for ICP waveform/

follows arterial pulse

brain layers csf absorption
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

csf flow path
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.
types of hydrocephalus
Communicating

Non-communicating or Obstructive

Normal Pressure Hydrocephalus

Congenital

Acquired

Types of Hydrocephalus
slide10

CT Scan Showing severe

hydrocephalus

Normal CT Scan

etiology of hydrocephalus
Etiology of Hydrocephalus
  • Communicating
    • Overproduction/underabsorption of CSF
    • Choroid Plexus Papilloma-overproduces CSF
    • SAH
    • Infection
    • Neoplasms affecting the meninges
    • Trauma
etiology of hydrocephalus12
Etiology of Hydrocephalus
  • Non-Communicating (Obstructive)
    • Aqueductal Stenosis
    • Arnold-Chiari Malformation (Cerebellar tonsils protrude into Foramen Magnum)
    • Cysts
    • Myelomeningocele
    • IVH
    • Tumors (particularly posterior fossa)
normal pressure hydrocephalus
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
signs symptoms associated with hydrocephalus
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
s s associated with hydrocephalus cont
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
Hydrocephalus
  • “SETTING SUN” EYES
s s associated with hydrocephalus cont18
S/S Associated with Hydrocephalus, cont.
  • Older Children & Adults
    • Persistent Vomiting
    • Headache**
    • Visual Problems
    • Lethargy
    • Behavior Changes
    • Difficulty with schoolwork
    • Seizures
diagnosis
Diagnosis
  • Clinical Evaluation
  • Ultrasound (Intrauterine & through Fontanels.
  • CT Scan
  • MRI
treatment modalities
Treatment Modalities
  • Surgical Procedures
    • Remove obstruction (Blood Clots, Tumors)
    • Endoscopic Third Ventriculostomy
    • Septal Fenestrations (Endoscopic)
    • Cyst Fenestrations (Endoscopic)
    • Shunt Insertion
interventions for hydrocephalus
Interventions for Hydrocephalus
  • If untreated:
  • *50-60% die of complications
  • If treated:
  • *40% normal intelligence
  • *70% live beyond infancy
historical treatment of hydrocephalous
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
historical treatment of hydrocephalous con t
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

heyer schulte and shunt industry history
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
heyer schulte and shunt industry history26
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
heyer schulte and shunt industry history27
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
what is a shunt
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.
how shunts work
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.
shunt systems
Shunt Systems
  • Ventriculo-peritoneal
  • Ventriculo-atrial
  • Lumbar-peritoneal
shunt components
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
shunt accessories
SHUNT ACCESSORIES
  • Proximal catheter stylet (can use endoscope)
  • Stylets for unitized shunts
  • Shunt passers
  • Connectors and Right angle guides
  • Shunt tap kits
  • Manometers
valve mechanisms
Valve Mechanisms
  • Differential Pressure Valves
  • Flow regulating devices
valve mechanisms42
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.
valve types
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
internal valve components
Internal Valve Components
  • Slit
  • Ball and Spring
  • Miter
  • Diaphragm
valve internal mechanisms
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)
valve mechanisms54
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?
slit valves
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
valve mechanisms58
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
Mitre Valves
  • Heyer-Schulte
    • Ultra-VS(cylindrical)
    • Mishler Dual Chamber (flat bottom)
    • Spetzler in-line Lumbar - Peritoneal valve (cylindrical)
valve mechanisms61
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
ball in cone valves
Ball-in-Cone Valves
  • Codman Medos Hakim
    • Medos Programmable
  • NMT/Cordis
    • Atlas
    • Hakim
    • Orbis Sigma II
  • Sophysa
    • Sophy Programmable
valve mechanisms64
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
diaphragm valves
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)
slide66

Diaphragm Valves

  • Radionics
    • Contour Flex
    • Equi-flow
    • Burr hole
  • Codman
    • Accu-flo valve
valve mechanisms68
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
slide69

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.
slide72

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.
treatment for siphoning
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
shunt failures and complications
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
shunt failures and complications76
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
shunt placement procedure
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
shunt implantation approaches
Shunt Implantation Approaches

Occipital Approach

Temporal Approach

Frontal Approach

slide79

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

indications for use of a lumbar peritoneal shunt
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.
goals of shunt design development
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
slide87

FLOW PATH

DELTA VALVE

slide92

LPV II Valve Performance

at High Flow Rates (45.8ml/hr)

LPV Valve Performance

at High Flow Rates (45.8ml/hr)

slide93

LPV II Valve Performance

at Low Flow Rates (4.6ml/hr)

LPV Valve Performance

at Low Flow Rates (4.6ml/hr)

competitive matrix
Competitive Matrix
  • Medtronic P.S. Medical
  • Cordis
  • Codman
  • Radionics
  • Sophysa
  • Phoenix
product line strengths
Product line strengths
  • Consistency and predictability
  • Broad product line
  • Clnical support
  • History
  • Manufacturing expertise
  • Pricing flexibility
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