Acta Neurochirurgica

, Volume 159, Issue 8, pp 1389–1397

Comparison of anti-siphon devices—how do they affect CSF dynamics in supine and upright posture?

  • Manuel Gehlen
  • Anders Eklund
  • Vartan Kurtcuoglu
  • Jan Malm
  • Marianne Schmid Daners
Original Article - Neurosurgical Techniques

Abstract

Background

Three different types of anti-siphon devices (ASDs) have been developed to counteract siphoning-induced overdrainage in upright posture. However, it is not known how the different ASDs affect CSF dynamics under the complex pressure environment seen in clinic due to postural changes. We investigated which ASDs can avoid overdrainage in upright posture best without leading to CSF accumulation.

Methods

Three shunts each of the types Codman Hakim with SiphonGuard (flow-regulated), Miethke miniNAV with proSA (gravitational), and Medtronic Delta (membrane controlled) were tested. The shunts were compared on a novel in vitro setup that actively emulates the physiology of a shunted patient. This testing method allows determining the CSF drainage rates, resulting CSF volume, and intracranial pressure in the supine, sitting, and standing posture.

Results

The flow-regulated ASDs avoided increased drainage by closing their primary flow path when drainage exceeded 1.39 ± 0.42 mL/min. However, with intraperitoneal pressure increased in standing posture, we observed reopening of the ASD in 3 out of 18 experiment repetitions. The adjustable gravitational ASDs allow independent opening pressures in horizontal and vertical orientation, but they did not provide constant drainage in upright posture (0.37 ± 0.03 mL/min and 0.26 ± 0.03 mL/min in sitting and standing posture, respectively). Consequently, adaptation to the individual patient is critical. The membrane-controlled ASDs stopped drainage in upright posture. This eliminates the risk of overdrainage, but leads to CSF accumulation up to the volume observed without shunting when the patient is upright.

Conclusions

While all tested ASDs reduced overdrainage, their actual performance will depend on a patient’s specific needs because of the large variation in the way the ASDs influence CSF dynamics: while the flow-regulated shunts provide continuous drainage in upright posture, the gravitational ASDs allow and require additional adaptation, and the membrane-controlled ASDs show robust siphon prevention by a total stop of drainage.

Keywords

Animal testing alternatives Anti-siphon device Cerebrospinal fluid shunt In vitro Overdrainage Posture 

References

  1. 1.
    Arnell K, Koskinen L-OD, Malm J, Eklund A (2009) Evaluation of strata NSC and Codman Hakim adjustable cerebrospinal fluid shunts and their corresponding antisiphon devices. J Neurosurg Pediatr 3(3):166–172CrossRefPubMedGoogle Scholar
  2. 2.
    Aschoff A, Kremer P, Benesch C, Fruh K, Klank A, Kunze S (1995) Overdrainage and shunt technology, a critical comparison of programmable, hydrostatic and variable-resistance valves and flow-reducing devices. Childs Nerv Syst 11(4):193–202CrossRefPubMedGoogle Scholar
  3. 3.
    Bergsneider M, Yang I, Hu X, McArthur DL, Cook SW, Boscardin WJ (2004) Relationship between valve opening pressure, body position, and intracranial pressure in normal pressure hydrocephalus: paradigm for selection of programmable valve pressure setting. Neurosurgery 55(4):851–859CrossRefPubMedGoogle Scholar
  4. 4.
    Chapman PH, Cosman ER, Arnold MA (1990) The relationship between ventricular fluid pressure and body position in normal subjects and subjects with shunts: a telemetric study. Neurosurgery 26(2):181–189CrossRefPubMedGoogle Scholar
  5. 5.
    Cobb WS, Burns JM, Kercher KW, Matthews BD, James Norton H, Todd Heniford B (2005) Normal intraabdominal pressure in healthy adults. J Surg Res 129(2):231–235CrossRefPubMedGoogle Scholar
  6. 6.
    Czosnyka Z, Czosnyka M, Richards HK, Pickard JD (1998) Posture-related overdrainage: comparison of the performance of 10 hydrocephalus shunts in vitro. Neurosurgery 42(2):327–333CrossRefPubMedGoogle Scholar
  7. 7.
    Czosnyka Z, Czosnyka M, Pickard JD (1999) Hydrodynamic performance of a new siphon preventing device: the SiphonGuard. J Neurol Neurosurg Psychiatry 66(3):408–410CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Czosnyka Z, Czosnyka M, Richards HK, Pickard JD (2002) Laboratory testing of hydrocephalus shunts—conclusion of the UK shunt evaluation programme. Acta Neurochir 144(6):525–538CrossRefPubMedGoogle Scholar
  9. 9.
    Czosnyka M, Czosnyka Z, Momjian S, Pickard JD (2004) Cerebrospinal fluid dynamics. Physiol Meas 25(5):R51–R76CrossRefPubMedGoogle Scholar
  10. 10.
    Czosnyka Z, Cieslicki K, Czosnyka M, Pickard JD (2005) Hydrocephalus shunts and waves of intracranial pressure. Med Biol Eng Comput 43(1):71–77CrossRefPubMedGoogle Scholar
  11. 11.
    Farahmand D, Qvarlander S, Malm J, Wikkelso C, Eklund A, Tisell M (2014) Intracranial pressure in hydrocephalus: impact of shunt adjustments and body positions. J Neurol Neurosurg Psychiatry 86(2):222–228CrossRefPubMedGoogle Scholar
  12. 12.
    Freimann FB, Sprung C (2012) Shunting with gravitational valves—can adjustments end the era of revisions for overdrainage-related events? Clinical article. J Neurosurg 117(6):1197–1204CrossRefPubMedGoogle Scholar
  13. 13.
    Freimann FB, Kimura T, Stockhammer F, Schulz M, Rohde V, Thomale UW (2014) In vitro performance and principles of anti-siphoning devices. Acta Neurochir 156(11):2191–2199Google Scholar
  14. 14.
    Gehlen M, Kurtcuoglu V, Schmid Daners M (2016) Patient specific hardware-in-the-loop testing of cerebrospinal fluid shunt systems. IEEE Trans Biomed Eng 63(2):348–358CrossRefPubMedGoogle Scholar
  15. 15.
    Gehlen M, Kurtcuoglu V, Schmid Daners M (2017) Is posture-related craniospinal compliance shift caused by jugular vein collapse? A theoretical analysis. Fluids and Barriers of the CNS 14(1)Google Scholar
  16. 16.
    Hassan M, Higashi S, Yamashita J (1996) Risks in using siphon-reducing devices in adult patients with normal-pressure hydrocephalus: bench test investigations with delta valves. J Neurosurg 84(4):634–641CrossRefPubMedGoogle Scholar
  17. 17.
    Kajimoto Y, Ohta T, Miyake H, Matsukawa M, Ogawa D, Nagao K, Kuroiwa T (2000) Posture-related changes in the pressure environment of the ventriculoperitoneal shunt system. J Neurosurg 93(4):614–617CrossRefPubMedGoogle Scholar
  18. 18.
    Miyake H, Ohta T, Kajimoto Y, Nagao K (2000) New concept for the pressure setting of a programmable pressure valve and measurement of in vivo shunt flow performed using microflow meter. J Neurosurg 92(1):181–187CrossRefPubMedGoogle Scholar
  19. 19.
    Portnoy HD, Schulte RR, Fox JL, Croissant PD, Tripp L (1973) Anti-siphon and reversible occlusion valves for shunting in hydrocephalus and preventing post-shunt subdural hematomas. J Neurosurg 38(6):729–738CrossRefPubMedGoogle Scholar
  20. 20.
    Qvarlander S (2013) Analysis of ICP pulsatility and CSF dynamics: the pulsatility curve and effects of postural changes, with implications for idiopathic normal pressure hydrocephalus. PhD thesisGoogle Scholar
  21. 21.
    Qvarlander S, Lundkvist B, Koskinen L-OD, Malm J, Eklund A (2013) Pulsatility in CSF dynamics: pathophysiology of idiopathic normal pressure hydrocephalus. J Neurol Neurosurg Psychiatry 84(7):735–741Google Scholar
  22. 22.
    Qvarlander S, Sundstrom N, Malm J, Eklund A (2013) Postural effects on intracranial pressure: modeling and clinical evaluation. J Appl Physiol 115(10):1474–1480Google Scholar
  23. 23.
    United States. National Aeronautics and Space Administration (1995) Man-systems integration standards. Number Bd. 3 in NASA-STD. National Aeronautics and Space AdministrationGoogle Scholar
  24. 24.
    Watson DA (1994) The delta valve: a physiologic shunt system. Childs Nerv Syst 10(4):224–230CrossRefPubMedGoogle Scholar
  25. 25.
    Williams MA, Malm J (2016) Diagnosis and treatment of idiopathic normal pressure hydrocephalus. Continuum Lifelong Learning Neurol 22(2):579–599CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria 2017

Authors and Affiliations

  • Manuel Gehlen
    • 1
    • 2
  • Anders Eklund
    • 3
  • Vartan Kurtcuoglu
    • 2
    • 4
    • 5
  • Jan Malm
    • 6
  • Marianne Schmid Daners
    • 7
  1. 1.Institute for Dynamic Systems and Control, Department of Mechanical and Process EngineeringETH ZurichZurichSwitzerland
  2. 2.The Interface Group, Institute of PhysiologyUniversity of ZurichZurichSwitzerland
  3. 3.Department of Radiation SciencesUmeå UniversityUmeåSweden
  4. 4.Neuroscience Center ZurichUniversity of ZurichZurichSwitzerland
  5. 5.Zurich Center for Integrative Human PhysiologyUniversity of ZurichZurichSwitzerland
  6. 6.Department of Pharmacology and Clinical NeuroscienceUmeå UniversityUmeåSweden
  7. 7.Product Development Group Zurich, Department of Mechanical and Process EngineeringETH ZurichZürichSwitzerland

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