Abstract
The first commercially produced adjustable valve for shunted hydrocephalus patients was introduced by H. Portnoy and R. Schulte in 1973. This valve is still in use and known as reversible occlusion or on–off valve. The reversible occlusion valve is mainly used in conjunction with an existing shunt in patients receiving intraventricular cytostatic therapy. The valve has a simple mechanical lock that is closed by external pressure application with a single finger. The study method is a retrospective clinical series of 15 patients undergoing a total of 16 valve implantations between 2003 and 2010 was carried out, and the valve was tested in vitro. We report a high incidence of accidental occlusions leading to a loss of consciousness in five patients (33.3%). We furthermore demonstrate in vitro that accidental occlusions can occur. The reversible occlusion valve is needed in shunted tumor patients receiving intrathecal administration of cytostatica. The mechanism works as long as no external pressure compresses the valve. However, head positions pose significant risks for unintentional occlusions. We stress the importance of: (1) a position near the midline avoiding the retroauricular or occipital regions, (2) a handling training for nurses and doctors, (3) instruction of patients and relatives, and (4) removal of the device after intrathecal cytostatic treatment.
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Acknowledgments
We thank Rezvan Ahmadi and Christine Dictus for intraoperative posing at an early stage of this project.
Conflict of interest
We have no conflicts of interest, either of financial or other nature. AMH is supported by a postdoctoral fellowship from the Exzellenzcluster CellNetworks, University of Heidelberg, Heidelberg, Germany.
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Henry W. S. Schroeder, Greifswald, Germany
Hertle et al. analyzed retrospectively a series of 13 patients treated with a reversible occlusion valve. The rationale for using this device was hydrocephalus in patients who were considered for intrathecal chemotherapy. In five patients, an incidental occlusion of the valve resulted in loss of consciousness. In addition to the clinical evaluation, lab investigations were performed to measure the pressure which is required to switch the valve to the “off” position.
Although this valve is rarely used today, the report is of interest to the readers because it shows the dangers which are inherent with this device. Even with low forces an unintended switch might occur. I agree with the authors that this valve should be replaced as soon as the intrathecal chemotherapy is finished.
Ernst Delwel, Rotterdam, The Netherlands
This is an important article on the evaluation of the reversible occlusion- or on–off valve as described by Portnoy and Schulte in 1973. The authors have retrospectively analyzed the results of 15 patients with a cerebrospinal fluid shunt in which a reversible occlusion- or on–off valve was interposed for intrathecal chemotherapy and have performed in vitro tests on three well-functioning explanted on–off valves and five unused on–off valves. One shunt infection occurred. In five of the 15 patients, accidental closure occurred with clinical signs and symptoms. Three of these patients were children. The occlusion was ascribed to external pressure on the valve in supine position. In vitro testing suggested that the application of a mass of 500–600 g would occlude the valve in about 50% of cases. The authors advise to implant the on–off valve in a position close to the midline to avoid compression during sleep but state that accidental occlusion can never be fully prevented. A further drawback of the on–off valve is the difficulty to check the valve position in vivo. In case of doubt a tangential X-ray is mandatory.
In addition to the reference list of the authors I have found one more relevant article dealing with the evaluation of the reversible occlusion- or on–off valve [1]. Czech et al. describe 15 pediatric patients with an active hydrocephalus and leptomeningeal metastases of primary malignant brain tumors treated with intrathecal chemotherapy via a reversible occlusion valve interposed in a ventriculoperitoneal shunt. The shunt was always closed for 2 h after injection of intrathecal chemotherapy. No shunt infection occurred and one accidental closure occurred in a 2-year-old boy who hit his head. The valves were implanted in the frontoparietal region to prevent occlusion by external pressure. The study of Czech et al. show some better results but they also report a case of accidental valve occlusion.
The conclusion that the reversible occlusion- or on–off valve is a useful tool in shunted tumor patients needing intrathecal administration of chemotherapy seems justified. However, one should stay alert on symptoms and signs of accidental occlusion which cannot fully be avoided. I would agree with the authors that a safer alternative valve should be developed.
Reference
[1]. Czech T, Reinprecht A, Dietrich W, Hainfellner JA, Slavc I: Reversible occlusion shunt for intraventricular chemotherapy in shunt-dependent brain tumor patients. Pediatr Hematol Oncol. 1997 Jul–Aug; 14(4): 375–80
Hartmut Collmann, Würzburg, Germany
The reversible occlusion valve has been developed for manual prevention of overdrainage in shunted hydrocephalus. It did not gain wide acceptance since inadvertent valve occlusion turned out to be a frequent side-effect. More recently, in the era of intraventricular cytostatic therapy, this device again attracted attention as it prevents too early egress of the intraventricular drug. In the present useful study, the authors substantiate the risk of unintentional valve occlusion merely by head position. However, they also convincingly show that the device can be used with sufficient safety if it is positioned in the high parietal region near the midline, where local pressure forces are rarely to be expected. They reasonably stress upon a special training in the handling of the device and its removal after intraventricular drug treatment has been completed.
Veit Rohde, Göttingen, Germany
On–off valves are implanted by some to allow intraventricular administration of antineoplastic drugs in hydrocephalic patients with brain tumors and meningiosis carcinomatosa without drug loss through the distal shunt. The experiences with on–off valves are limited despite their introduction into the market almost 40 years ago, and recent well-done publications are rare. Therefore, a series addressing the usefulness and safety of on–off valves would be timely and possibly stimulated the authors to retrospectively analyze their patient population and to perform in vitro testing. The authors reported their experiences in 15 patients, in which an on–off valve was implanted within the last 7 years. Five patients experienced accidental occlusion of the valve, being life threatening in two. Three of the five patients were children. In two of the three children, the position of the valve enabled frequent head-on valve positions. In vitro testing of three explanted and five unused valves showed that masses smaller than 270 g already could occlude the valve. If a patient simulator, in which the valve is covered with artificial material, was used, the mass which has the potential to occlude the valve increased to 300–400 g. The strength of the article is the in vitro testing which indicates that the risk of inadvertent occlusion is high. The obvious weakness of the article is the clinical part due to its retrospective design and the very small sample size. The clinical series resembles that of a compilation of cases, without uniform surgical management, and no obvious postoperative management strategy. Nonetheless, the case series seems to support the in vitro findings of easy and frequent accidental occlusion. This raises the question if on–off valves indeed should be used in the future, or if less risky (but possibly less effective) alternatives such as lumbar intrathecal administration of antineoplastic drugs or intraventricular administration using a shunt reservoir and accepting drug loss through the distal catheter should be preferred.
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Hertle, D.N., Tilgner, J., Fruh, K. et al. Reversible occlusion (on–off) valves in shunted tumor patients. Neurosurg Rev 34, 235–242 (2011). https://doi.org/10.1007/s10143-010-0297-y
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DOI: https://doi.org/10.1007/s10143-010-0297-y