Flow-regulated versus differential pressure valves for idiopathic normal pressure hydrocephalus: comparison of overdrainage rates and neurological outcome

  • Christian Wetzel
  • Lukas GoertzEmail author
  • Philipp Noé
  • Niklas von Spreckelsen
  • Marina Penner
  • Christoph Kabbasch
  • Roland Goldbrunner
  • Boris Krischek
Original Article - CSF Circulation
Part of the following topical collections:
  1. CSF Circulation



To compare flow-regulated (FR) and differential pressure (DP) valves for treatment of patients with idiopathic normal hydrocephalus (iNPH) focusing on overdrainage and neurological outcome.


This is a retrospective study of patients with iNPH treated with FR and DP valves at a single institution between 2008 and 2018. The neurological status was evaluated retrospectively with the Kiefer scale at baseline, after shunt placement and at the 6-month follow-up. Groups were compared using inverse probability of treatment weighting based on propensity scores.


The study cohort consisted of 38 patients treated with FR valves and 49 with DP valves. The mean patient age was 72.0 ± 7.6 years. Based on the Kiefer scale score, neurological improvement at the 6-month follow-up was recorded in 79.6% in the DP group and 89.5% in the FR group (p = 0.252). The overdrainage rates were higher among DP valves (10.2%) than among FR valves (2.6%, adjusted p = 0.002). Valve malfunction occurred in 2.0% in the DP group and 5.3% in the FR group (adjusted p = 0.667).


The current study demonstrates a comparable neurological improvement between DP and FR valves, with potentially lower overdrainage rates among FR valves. Long-term studies will be necessary to draw a definite conclusion on FR valves for treatment of iNPH patients.


Differential pressure valve Flow-regulated valve iNPH Normal pressure hydrocephalus Overdrainage 


Funding information

This study was supported by a grant provided by Integra® LifeSciences (Integra LifeSciences Services, Lyon, France).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

For this type of study formal consent is not required.

Informed consent

Informed consent was obtained from all individual participants included in the study.


The sponsor had no role in the design or conduct of this research.


  1. 1.
    Adams R, Fisher C, Hakim S, Ojemann R, Sweet W (1965) Symptomatic occult hydrocephalus with normal cerebrospinal-fluid pressure: a treatable syndrome. N Engl J Med 273:117–126CrossRefGoogle Scholar
  2. 2.
    Bergsneider M, Black PM, Klinge P, Marmarou A, Relkin N (2005) Surgical management of idiopathic normal-pressure hydrocephalus. Neurosurgery 57:S2-29-S22-39CrossRefGoogle Scholar
  3. 3.
    Bozhkov Y, Roessler K, Hore N, Buchfelder M, Brandner S (2017) Neurological outcome and frequency of overdrainage in normal pressure hydrocephalus directly correlates with implanted ventriculo-peritoneal shunt valve type. Neurol Res 39:601–605CrossRefGoogle Scholar
  4. 4.
    Capitanio JF, Venier A, Mazzeo LA, Barzaghi LR, Acerno S, Mortini P (2016) Prosepective study to evaluate rate and frequency of perturbations of implanted programmable Hakim Codman valve after 1.5-Tesla magnetic resonance imaging. World Neurosurg 88:297–299CrossRefGoogle Scholar
  5. 5.
    Carmel PW, Albright AL, Adelson PD, Canady A, Black P, Boydston W, Kneirim D, Kaufman B, Walker M, Luciano M (1999) Incidence and management of subdural hematoma/hygroma with variable-and fixed-pressure differential valves: a randomized, controlled study of programmable compared with conventional valves. Neurosurg Focus 7:E8CrossRefGoogle Scholar
  6. 6.
    de Jong DA, Delwel EJ, Avezaat CJ (2000) Hydrostatic and hydrodynamic considerations in shunted normal pressure hydrocephalus. Acta Neurochir 142:241–247CrossRefGoogle Scholar
  7. 7.
    Gehlen M, Eklund A, Kurtcuoglu V, Malm J, Daners MS (2017) Comparison of anti-siphon devices—how do they affect CSF dynamics in supine and upright posture? Acta Neurochir 159:1389–1397CrossRefGoogle Scholar
  8. 8.
    Gölz L, Lemcke J, Meier U (2013) Indications for valve-pressure adjustments of gravitational assisted valves in patients with idiopathic normal pressure hydrocephalus. Surg Neurol Int 4CrossRefGoogle Scholar
  9. 9.
    Kiefer M, Eymann R, Komenda Y, Steudel W (2003) Ein Graduierungssystem für den chronischen Hydrozephalus. Zentralbl Neurochir 64:109–115CrossRefGoogle Scholar
  10. 10.
    Kim KH, Yeo IS, Yi JS, Lee HJ, Yang JH, Lee IW (2009) A pressure adjustment protocol for programmable valves. J Korean Neurosurg Soc 46:370–377CrossRefGoogle Scholar
  11. 11.
    Klinge P, Hellstrom P, Tans J, Wikkelso C (2012) One-year outcome in the European multicentre study on iNPH. Acta Neurol Scand 126:145–153CrossRefGoogle Scholar
  12. 12.
    Lemcke J, Meier U, Müller C, Fritsch MJ, Kehler U, Langer N, Kiefer M, Eymann R, Schuhmann MU, Speil A (2013) Safety and efficacy of gravitational shunt valves in patients with idiopathic normal pressure hydrocephalus: a pragmatic, randomised, open label, multicentre trial (SVASONA). J Neurol Neurosurg Psychiatry 84:850–857CrossRefGoogle Scholar
  13. 13.
    Shaw R, Everingham E, Mahant N, Jacobson E, Owler B (2016) Clinical outcomes in the surgical treatment of idiopathic normal pressure hydrocephalus. J Clin Neurosci 29:81–86CrossRefGoogle Scholar
  14. 14.
    Suchorska B, Kunz M, Schniepp R, Jahn K, Goetz C, Tonn J, Peraud A (2015) Optimized surgical treatment for normal pressure hydrocephalus: comparison between gravitational and differential pressure valves. Acta Neurochir 157:703–709CrossRefGoogle Scholar
  15. 15.
    Sulter G, Steen C, De Keyser J (1999) Use of the Barthel index and modified Rankin scale in acute stroke trials. Stroke 30:1538–1541CrossRefGoogle Scholar
  16. 16.
    Wetzel C, Goertz L, Schulte AP, Goldbrunner R, Krischek B (2018) Minimizing overdrainage with flow-regulated valves - initial results of a prospective study on idiopathic normal pressure hydrocephalus. Clin Neurol Neurosurg 173:31–37CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Faculty of Medicine and University Hospital, Center for NeurosurgeryUniversity of CologneCologneGermany
  2. 2.Department of NeurosurgeryBundeswehrkrankenhaus KoblenzKoblenzGermany
  3. 3.Harvey Cushing Neuro-Oncology Laboratories, Department of Neurosurgery, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA
  4. 4.Department of NeuroradiologyUniversity Hospital of CologneCologneGermany

Personalised recommendations