In vitro testing of explanted shunt valves in hydrocephalic patients with suspected valve malfunction

Abstract

Diagnosis of symptomatic valve malfunction in hydrocephalic patients treated with VP-Shunt (VPS) might be difficult. Clinical symptoms such as headache or nausea are nonspecific, hence cerebrospinal fluid (CSF) over- or underdrainage can only be suspected but not proven. Knowledge concerning valve malfunction is still limited. We aim to provide data on the flow characteristics of explanted shunt valves in patients with suspected valve malfunction. An in vitro shunt laboratory setup was used to analyze the explanted valves under conditions similar to those in an implanted VPS. The differential pressure (DP) of the valve was adjusted stepwise to 20, 10, 6, and 4 cmH₂O. The flow rate of the explanted and the regular flow rate of an identical reference valve were evaluated at the respective DPs. Twelve valves of different types (Codman CertasPlus valve n = 3, Miethke Shuntassistant valve n = 4, Codman Hakim programmable valve n = 3, DP component of Miethke proGAV 2.0 valve n = 2) from eight hydrocephalic patients (four male), in whom valve malfunction was assumed between 2016 and 2017, were replaced with a new valve. Four patients suffered from idiopathic normal pressure (iNPH), three patients from malresorptive and one patient from obstructive hydrocephalus. Post-hoc analysis revealed a significant difference (p < 0.001) of the flow rate between each explanted valve and their corresponding reference valve, at each DP. In all patients, significant alterations of flow rates were demonstrated, verifying a valve malfunction, which could not be objectified by the diagnostic tools used in the clinical routine. In cases with obscure clinical VPS insufficiency, valve deficiency should be considered.

Keywords: Hydrocephalus; Shunt failure; Shunt valve; Ventriculo peritoneal shunt.

Fig. 1

Schematic drawing of the experimental set-up.

Fig. 2

Exemplary images of the tested devices, (a) Codman CertasPlus valve, (b) Miethke gravity-regulated Shuntassistant, (c) the DP-component of the proGAV 2.0 valve, (d) Codman Hakim programmable valve

Fig. 3

Baseline measurement showing a linear increase in flow rate with increasing differential pressure (DP) in the control measurement

Fig. 4

Significant flow alteration between all three explanted Codman CertasPlus devices and their corresponding reference valve at each 20, 10, 6 and 4 DP (p < 0.001)

Fig. 5

Significant flow alteration between all four explanted Miethke gravity-regulated Shuntassistant devices and their corresponding reference valve at each 20, 10, 6 and 4 DP (p < 0.001)

Fig. 6

Significant flow alteration between all two explanted DP-components of the Miethke proGAV 2.0 valve and their corresponding reference valve at each 20, 10, 6 and 4 DP (p < 0.001)

Fig. 7

Significant flow alteration between all three explanted Codman Hakim Programmable valve and their corresponding reference valve at each 20, 10, 6 and 4 DP (p < 0.001)