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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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Xix congress of the european society for pediatric neurosurgery rome may 6 9th 2004

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: Alfred_Aschoff@med.uni-heidelberg.de

Oral presentation on Sunday, May 9th, 2004 Selectedslides


Xix congress of the european society for pediatric neurosurgery rome may 6 9th 2004

Shunt-Revisions: Neurosurgery Quantities

Misplaced catheters

Hydraulic Mismanagement

Infections

Disconnections


Xix congress of the european society for pediatric neurosurgery rome may 6 9th 2004

Ventricular Catheters - Positions Neurosurgery 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


Xix congress of the european society for pediatric neurosurgery rome may 6 9th 2004

±3 Neurosurgeryo

Catheter,ideal position= all holesfree in the ventricle

Tolerance for lateral deviations ±3o only!


Xix congress of the european society for pediatric neurosurgery rome may 6 9th 2004

Current Quotes of Shunt-Infections Neurosurgery

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


Xix congress of the european society for pediatric neurosurgery rome may 6 9th 2004

1. Sterility in the NeurosurgeryOP-theatre

2. Antibacterial surface modification of implant

3. Systemic antibiotic prophylaxis


Xix congress of the european society for pediatric neurosurgery rome may 6 9th 2004

55 rabbits, prospective, randomized Neurosurgery 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


Xix congress of the european society for pediatric neurosurgery rome may 6 9th 2004

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

Inaccuracies & long-term-drifts common


Xix congress of the european society for pediatric neurosurgery rome may 6 9th 2004

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

Instable valve bodiesReflux …


Xix congress of the european society for pediatric neurosurgery rome may 6 9th 2004

Adjustable Valves: Neurosurgery Change of Technological Leadership ?

Miethke ProGAVSophysa-Polaris+ gravitational valve

Codman-Medos


Xix congress of the european society for pediatric neurosurgery rome may 6 9th 2004

Adjustable Valves – Present Use Neurosurgery

Treatment of self-produced complications (preferebly overdrainage)

Fine tuning for individual needs

Psychotherapy

Training to shunt-independence


Xix congress of the european society for pediatric neurosurgery rome may 6 9th 2004

Adjustable Valves Neurosurgeryand 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


Xix congress of the european society for pediatric neurosurgery rome may 6 9th 2004

Adjustable Valves – Use in Future Neurosurgery

Training to shunt-independence

Fine tuning for individual needs

Psychotherapy

Treatment of self-produced complications


Xix congress of the european society for pediatric neurosurgery rome may 6 9th 2004

G- + adjustable valve Neurosurgery

adjustable alone

Ball- + g-valve

1

2

3


Xix congress of the european society for pediatric neurosurgery rome may 6 9th 2004

Gravitational Valves Neurosurgery - 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


Xix congress of the european society for pediatric neurosurgery rome may 6 9th 2004

Gravitational Valves Neurosurgery- Perspectives

Adjustable g-Valves

Percutaneous variation

- Number of “active“ balls

- Balls with different weights

- Variation of the cone-geometry


Xix congress of the european society for pediatric neurosurgery rome may 6 9th 2004

Shunt Technology in 2005 Neurosurgery

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


Xix congress of the european society for pediatric neurosurgery rome may 6 9th 2004

Shunt Technology in 2010 Neurosurgery

- 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