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Understand the problem

Treatment of hydrocephalus need for action

Hydrocephalus, the excess buildup of cerebrospinal fluid in the brain, can affect all age groups.

Why does it need better solutions for the treatment of hydrocephalus?

Challenges for hydrocephalus shunts

Shunts are life-saving devices but despite long-term experience with shunt implantation and the continuing development of shunt technology they are notorious for high failure rates. [1] Further, conventional shunts fail to address the posture-dependent gravitational effects that influence shunt performance. Overdrainage-related complications can necessitate a variety of different reoperations, which are burdensome for patients and are accompanied by unavoidable perioperative risks.

Revisions and complications

High failure rates continue to overshadow the effectiveness of shunts. [10] It is generally estimated that 40% of shunts fail within 2 years and 98% within 10 years, [1] with no difference between different conventional valves [11] and programmable valves. [12] Nearly every fourth patient is affected by complications, and little improvement in reducing these complications has been made. [13] The most common cause for mechanical complications is obstruction of valve or catheters [14] but a relatively high frequency of non-traumatic subdural hematoma, a potential complication of overdrainage, has also been reported. [13]

Mechanical failure

Mechanical failure is the most common cause of multiple shunt revisions, [2] with catheter or valve obstruction being the predominant reason. [14] However, failure of individual shunt components may also occur, e.g., at stress points or due to poor design. [15]

Accidental reprogramming

Pressure settings of adjustable valves can be reprogrammed by low-intensity magnetics fields, which are ubiquitous in today’s environment. Smartphones, [5] headphones, [6] tablet devices [7] and even toy magnets [8], [9] have been shown to change the pressure settings of adjustable shunt valves.

The optimal pressure setting of the adjustable valves is of great importance for the patient. Therefore, it comes as no surprise that the possibility of accidental valve adjustments in everyday life is a cause of concern and leads to great uncertainty among patients and doctors alike.

No two patients are alike

When choosing valves it is important to select the type of valve individually in each patient according to the type of hydrocephalus as well as the anticipated postoperative management needs. [9]

Are conventional adjustable valves the best available therapy?

Treatment with conventional adjustable valves always means finding a compromise:

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MIETHKE gravitational valves

Learn more about how to overcome the challenges of conventional adjustable valves with gravitational shunts.
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Challenges for hydrocephalus shunt development

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[1] Lutz BR, Venkataraman P, Browd SR. New and improved ways to treat hydrocephalus: Pursuit of a smart shunt. Surg Neurol Int 2013;4(Suppl 1):S38-50.

[2] Beuriat PA, Puget S, Cinalli G et al. Hydrocephalus treatment in children: long-term outcome in 975 consecutive patients. J Neurosurg Pediatr 2017 20:10-18

[3] Merkler AE, Ch‘ang J, Parker WE, Murthy SB, Kamel H. The Rate of Complications after Ventriculoperitoneal Shunt Surgery. World Neurosurg 2017 98:654-658

[4] Browd SR., Ragel BT., Gottfried ON. and Kestle JR. Failure of cerebrospinal fluid shunts: part I: Obstruction and mechanical failure. Pediatr Neurol 2006 34(2): 83-92

[5] Ozturk S, Cakin H, Kurtuldu H, Kocak O, Erol FS, Kaplan M. Smartphones and Programmable Shunts: Are These Indispensable Phones Safe and Smart? World Neurosurg 2017 102:518-525

[6] Spader HS, Ratanaprasatporn L, Morrison JF, Grossberg JA, Cosgrove GR. Programmable shunts and headphones: Are they safe together? J Neurosurg Pediatr 2015 16:402-405

[7] Strahle J, Selzer BJ, Muraszko KM, Garton HJ, Maher CO. Programmable shunt valve affected by exposure to a tablet computer. J Neurosurg Pediatr 2012 10:118-120

[8] Anderson RC, Walker ML, Viner JM, Kestle JR. Adjustment and malfunction of a programmable valve after exposure to toy magnets. Case report. J Neurosurg 2004 101:222-225

[9] Zuzak TJ, Balmer B, Schmidig D, Boltshauser E, Grotzer MA. Magnetic toys: forbidden for pediatric patients with certain programmable shunt valves? Childs Nerv Syst 2009 25:161-164

[10] Freimann FB, Sprung C. Shunting with gravitational valves--can adjustments end the era of revisions for overdrainage-related events?: clinical article. J Neurosurg 2012;117(6):1197-204.

[11] Gutierrez-Murgas Y, Snowden JN. Ventricular shunt infections: immunopathogenesis and clinical management. J Neuroimmunol 2014;276(1-2):1-8.

[12] Drake JM, Kestle JR, Milner R, et al. Randomized trial of cerebrospinal fluid shunt valve design in pediatric hydrocephalus. Neurosurgery 1998;43(2):294-303; discussion -5.

[13] Pollack IF, Albright AL, Adelson PD. A randomized, controlled study of a programmable shunt valve versus a conventional valve for patients with hydrocephalus. Hakim-Medos Investigator Group. Neurosurgery 1999;45(6):1399-408; discussion 408-11.

[14] Merkler AE, Ch'ang J, Parker WE, et al. The Rate of Complications after Ventriculoperitoneal Shunt Surgery. World Neurosurg 2017;98:654-8.

[15] Chiriac A, Poeata I, Iliescu B. Mechanical failures of ventriculo-peritoneal shunts. Romanian Neurosurgery 2012;XIX(3):226-9.

[16] Woerdeman PA, Cochrane DD. Disruption of silicone valve housing in a Codman Hakim Precision valve with integrated Siphonguard. J Neurosurg Pediatr 2014;13(5):532-5.

[17] Miyake H. Shunt Devices for the Treatment of Adult Hydrocephalus: Recent Progress and Characteristics. Neurol Med Chir (Tokyo) 2016;56(5):274-83.

[18] Powell A, Savin S, Savva N. Physician Workload and Hospital Reimbursement: Overworked Physicians Generate Less Revenue per Patient. Manufacturing & Service Operations Management 2012;14(4):512-28.

[19] Irving G, Neves AL, Dambha-Miller H, et al. International variations in primary care physician consultation time: a systematic review of 67 countries. BMJ Open 2017;7(10):e017902.

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