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Acta Neurochir (2010) 152:17931800 DOI 10.



Miethke DualSwitch Valve in lumboperitoneal shunts

Suhas Udayakumaran & Jonathan Roth & Anat Kesler & Shlomi Constantini

Received: 4 May 2010 / Accepted: 17 June 2010 / Published online: 4 July 2010 # Springer-Verlag 2010

Abstract Introduction Despite the existence of wide variety of shunt systems, physiological regulation of intracranial pressure in shunted patients remains a utopian dream. Lumboperitoneal shunts (LPS) have long been used for treating idiopathic intracranial hypertension and other types of communicating hydrocephalus. Although they can provide rapid and effective symptom resolution, cerebrospinal fluid (CSF) over-drainage remains a common complication of LPS. We introduce the use of the Miethke DualSwitch Valve (MDSV) for LPS and describe our preliminary experience with these valves in managing and avoiding CSF overdrainage. This is the first description of the use of M-DSV for LPS. Materials and methods Over 6 months, we treated five patients with LPS using M-DSV. Prior to the use of the MDSV, four patients experienced significant over-drainage symptoms secondary to LPS. Data was collected prospectively, including preoperative details and clinical outcome. Results Five patients (age range, 22 to 71 years) were operated upon. Three patients had pseudotumor cerebri, one patient had an LPS for treatment of a posterior fossa

pseudomeningocele, and one had an LPS for treatment of cauda equina syndrome secondary to lumbar dural ectasia. Four patients had a history of clinical over-drainage secondary to pre-existing LPS systems. The fifth patient had an LPS revision after the previous LPS migrated. Follow-up ranged from 5 to11 months (mean, 7.8 3 months). All patients had a good outcome with immediate resolution of over-drainage symptoms and are currently asymptomatic. Conclusions The use of M-DSV in LPS is an effective alternative for avoiding posture-related over-drainage and managing patients with LPS-related over-drainage symptoms. Further experience is required to address the long-term outcome, balancing sufficient drainage while preventing over-drainage. Keywords Lumboperitoneal shunt . Over-drainage . Miethke DualSwitch Valve . Gravity-assisted valve . Pseudotumor cerebri . Intracranial pressure

Introduction Physiological regulation of intracranial pressure (ICP) has been an unachievable goal since the introduction of shunts for cerebrospinal fluid (CSF) diversion despite the development of over 200 different types of shunts with more than thousand pressure permutations within the last 50 years [1]. Lumboperitoneal shunts (LPS) have long been used for the treatment of idiopathic intracranial hypertension (pseudotumor cerebri (PTC)), postoperative pseudomeningocele, CSF leaks, and "communicating hydrocephalus". Although they can provide a rapid and effective resolution of symptoms, there are major disadvantages associated with LPS use, such as posture-related CSF over-drainage and its

S. Udayakumaran (*) : J. Roth : S. Constantini (*)

Department of Pediatric Neurosurgery, Dana Childrens Hospital, Tel Aviv University, Tel Aviv Sourasky Medical Center, 6 Weizman Street, Tel Aviv 64239, Israel e-mail: e-mail: A. Kesler Neuro-ophthalmology Unit, Department of Ophthalmology, Tel Aviv University, Tel Aviv Sourasky Medical Center, 6 Weizman Street, Tel Aviv 64239, Israel


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myriad manifestations, occasionally associated with acquired Chiari malformation [2]. Various methods have been used to avoid or manage CSF over-drainage with LPS, including upgrading the shunt to higher-pressure settings, using programmable valves, and using flow-restricting or hydrostatic devices [35]. Hydrostatic valves take into account the patients posture, restricting CSF drainage during upright positions. The Miethke DualSwitch Valve (M-DSV) system is a type of horizontalvertical (HV) switcher type of hydrostatic valve with its resistance depending on the patient position. Since its introduction in 1994 by Miethke and co-workers, the DualSwitch Valve has been used effectively to avoid and manage over-drainage in different types of adult hydrocephalus [1, 69]. Flow-restricting devices, as a rule, require the device placement parallel to the body axis, making it cumbersome to use together with LPS. The M-DSV designed for LPS can conveniently be interposed in line with the shunt tubing. This, along with many other advantages described in this paper, makes it an attractive device for LPS. We introduce the use of the M-DSV to avoid and manage over-drainage in LPS and describe our preliminary experience with these valves for LPS. This is the first case series focusing on the use of M-DSV as a restrictive component in LPS.

Fig. 1 Schematic representation of the valve technology. 1Inlet connecting to the intrathecal catheter. 2 Outlet towards the peritoneal catheter. 3 Low-pressure chamber. 4 High-pressure chamber. 5 Ball responsible ("switch") for toggling between pressure chambers depending on the position

Materials and methods During the period of June to December 2009, we treated five patients with LPS using an M-DSV. All patients had LPS revisions with the M-DSV, four for clinically significant over-drainage (presenting with new-onset positional headaches) and one for distal shunt migration. Prospectively collected data included patient demographics, clinical status (including details of prior surgeries and preoperative neurological and neuro-ophthalmological status), operative findings, and clinical and neuroophthalmological follow-up. The M-DSV technology The M-DSV valve consists of two integrated chambers, each with a different opening pressure ( The low-pressure chamber is activated when the patient is recumbent. The high-pressure chamber is activated when the patient is in an upright position. Toggling between chambers is by a heavy tantalum sphere which occludes the drainage through the low-pressure chamber as soon as the patient is in upright position (Fig. 1). Switching between pressure settings is not gradual but occurs at an angle of about 60-70 (C. Miethke, personal communication, 2009). For example, the actual opening pressure in a 10/40 M-

DSV is 10 cm H2O when at an angle between 0 (supine) to 60-70, and 40 cm H2O when at an angle between 60-70 to 90 (upright). Thus, the ICP is kept in a physiological range whether the patient is supine or upright (C. Miethke, personal communication, 2009). The M-DSV has been evaluated in adult hydrocephalus and has been found to maintain ICP within physiological limits independent of patient posture [1, 6, 8, 9]. The M-DSV is available with opening pressures of 5, 10, 13, and 16 cm H2O for the supine position and 30, 40, and 50 cm H2O for the upright position. When supine, the MDSV operates like a conventional differential pressure valve. The recommended standard pressure setting for the lower-pressure valve, according to the manufacturer (C. Miethke GmbH & Co. KG) is 10 cm H2O (5 cm H2O for patients with normal-pressure hydrocephalus (NPH)). The high-pressure side of the valve is calculated as a function of the sitting height and is chosen in such a way that with the patient upright, a ventricular pressure of at least 5 cm H2O will be maintained under all circumstances (C. Miethke GmbH & Co. KG). Suitable pressure is calculated as follows: 1 Measure the distance between the third ventricle (at the level of the foramen of Monro, as roughly measured from the external auditory meatus) and the patients diaphragm (as roughly measured at the level of the costal arch). 2 Subtract 5 cm from the measured distance. 3 Choose a valve whose high-pressure setting exceeds the final measured value by the smallest amount. Ventricular pressure in the patient will then be kept between 5 cm H2O and +5 cm H2O at all times. Surgical aspects of the M-DSV The M-DSV valve is interposed and placed in the abdominal wall (or at the flank) (manufacturer's recom-

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mendation: arcus costalis). The valve function requires it be placed in an axis parallel to the body (direction as indicated by an arrow on the valve). The specific design of the MDSV meant for the LPS has a perpendicular connector allowing it to be interposed in line with the LPS [Fig. 2]. An antechamber that can be used for pressure measurement and fluid aspiration is located proximal to the valve. The antechamber has a narrow connecter for connection with the intrathecal catheter. The valve is connected distally to an abdominal catheter for intra-peritoneal insertion; alternatively, it can be connected to a pre-existing distal abdominal catheter using a straight connector. The valve may be anchored to the tissue layers using sutures to maintain its orientation with respect to the axis of the body. We used a valve with opening pressures of 10/40 for all five patients in accordance with their sitting height. The patients were regularly followed, and the outcomes were evaluated based on the preoperative and postoperative symptomatology.

LPS and for using the M-DSV, and follow-up are summarized in Table 1. Initial indications for LPS Three patients had PTC, one patient had an LPS for treatment of a posterior fossa pseudomeningocele (following an excision of a tentorial meningioma), and one elderly patient had an LPS for treatment of cauda equina syndrome secondary to a lumbar dural ectasia associated with ankylosing spondylitis. Indications for LPS revision Four patients (all females) had a history of postural headaches consistent with over-drainage, secondary to pre-existing LPS systems. One of the patients had a history of upgrading her valve (medium pressure to Delta 2); two patients had a prior LPS, one with a medium-pressure valve (PS medical, Medtronic) and another with a Delta 1.5 valve. The fourth patient, with a valveless LPS for PTC, presented with visual deterioration associated with postural headaches that were attributed to over-drainage secondary to LPS and not raised ICP. The fifth patient, an elderly male, had an LPS revision with an M-DSV after the previous LPS (placed for treatment of a symptomatic lumbar dural ectasia) migrated. Operative and perioperative course Four valves were placed along the right side and one along the left. There were no technical difficulties in any of the patients, including in the three PTC patients who were severely obese. Patients were discharged within 23 days following surgery. There were no exacerbations of preoperative symptoms following surgery. One patient required a distal revision 2 weeks later for proximal migration of the peritoneal catheter to the new valve pocket. Long-term follow-up Average follow-up was 7.83 months, ranging from 5 to 11 months. All four patients presenting with overdrainage symptoms had immediate significant improvement and are currently asymptomatic. There were no exacerbations in any of the PTC patients. The patient who presented with visual deterioration experienced improvement. The patient with the cauda equina syndrome secondary to a lumbar dural ectasia has had complete relief of his symptoms with no symptoms of overdrainage. None of the patients had any ophthalmological sequelae.

Results From June to December 2009, we treated five patients, four females and one male, ages ranging from 22 to 71 years. Patient demographic data, clinical history, indications for

Fig. 2 Photograph of the valve constituents. The arrows show the inlet (1) to the valve and outlet (2) from the valve. The inlet has a narrow connecter for the intrathecal catheter and leads to an antechamber. The outlet has a connector for the abdominal catheter for intra-peritoneal insertion. An arrow on the valve indicates the direction of the valve, to be placed parallel to the body axis. Notice that the M-DSV meant for LPS has been specifically designed with perpendicular connectors to allow it to be easily interposed in line with the LPS. The valve may be anchored to the tissue layers using sutures to maintain its orientation with respect to the axis of the body

1796 Outcome after LPS with M-DSV Clinical over-drainage Improved in clinical symptoms with normal vision, and fundus Clinical over-drainage Improved symptoms, no pseudomeningocele

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Postoperative pseudomeningocele Cystoperitoneal shunt Y VPS Postural headaches after surgery for tentorial (Medium-pressure valve), meningioma malfunction Y LPS with medium-pressure valve Ankylosing spondylitis with LPS that migrated. Nonfunctional Urinary incontinence and LPS malfunction Improved symptoms symptomatic dural ectasia pseudomeningocele of the lumbar area PTC with optic nerve fenestration Delta 1.5 Postural headaches Clinical over-drainage Improved symptoms PTC Valveless Postural headaches, Visual Clinical over-drainage Improved symptoms deterioration, ICP showed negative value; Fundus-optic atrophy

Illustrative case A 22-year-old obese female presented with severe and constant headaches. Her neurological examination was normal apart from bilateral papilledema. Imaging was unremarkable, and she was diagnosed with PTC. She failed a trial of conservative measures including weight loss and medical therapy with Diamox (acetazolamide) as she developed side effects. Subsequently, an LPS with a medium-pressure valve (PS Medical, Medtronic) was inserted. Although she initially experienced marked improvement in her headaches, she later began complaining of positional headaches which improved on recumbent position. She had no significant relief of symptoms with conservative measures over a period of 1 year. One of the episodes was severe enough to bring her to the emergency department. An urgent head CT and shunt radiographs completed during this episode were normal. Puncture of the shunt chamber revealed free flow but a very low pressure of 2 cm H2O. Two months later, with a provisional diagnosis of lowpressure headaches, she underwent a valve upgrade to a Delta 2 (PS Medical, Medtronic). The headaches initially improved but the effect wore off, and she continued to suffer substantial headaches, especially when in the upright position. The headaches worsened with physical activity and led to severe impairment of quality of life. Eight months later, she underwent a valve revision with an MDSV 10/40. The patient improved immediately after surgery and no longer complained of postural headaches. At 11-month follow-up, she continues to remain symptom free with a normal fundus.

Indication for LPS revision Clinical Features Valve used prior to M-DSV

Medium pressure (PS medical), over-drainage Y (Delta 2.0)

Postural headaches

Y: represents change to, following symptoms of overdrainage.

Several authors have reported a clear reduction in the incidence of over-drainage among patients with adult hydrocephalus treated by ventriculoperitoneal shunts (VPS) with M-DSV [1, 610]. In view of these previously published results showing the advantage of M-DSV in VPS for various hydrocephalic pathologies in adults, we opted to utilize the M-DSV in our patients with LPS. Our series is the first series focusing on the usage of M-DSV for LPS in an attempt to avoid and manage posture-related over-drainage. Since the introduction of LPS in the 1950s and silastic catheters in 1975 by Selman et al. [11], LPS have evolved as an important option for CSF diversion, serving as an alternative to VPS for several indications [11, 12]. LPS have been used to treat a host of conditions including CSF rhinorrhea, normal pressure hydrocephalus, lumbar pseudomeningocele, slit ventricle syndrome, and in particular PTC [13, 14].

Serial no: Patient characteristics Indication for LPS

Table 1 Patient details





4 5

28/F 30/F

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LPS offer numerous advantages over VPS including avoidance of the need to access ventricular cavities within the brain parenchyma, thereby avoiding potential complications such as cortical venous injury or hemorrhage, as well as lower seizure and infection rates [15, 16] and a very low mortality rate compared to VPS [5, 17]. In the context of communicating hydrocephalus, LPS are probably more physiological, maintaining patency of all ventricular cavities compared to a VPS [18], as they access CSF from both the ventricles and cortical subarachnoid spaces through the spinal subarachnoid space. Although LPS provide rapid and effective resolution of the primary symptoms, several disadvantages are associated with their use. Complication rates associated with the current LPS systems are considered high [17]. Orthostatic over-drainage and its myriad manifestations are especially a concern when using LPS [14]. The incidence of symptomatic over-drainage secondary to LPS is reported to be as high as 15-20% [1921]. Although over-drainage is a general concern when placing an LPS, patients who receive LPS with valves had a lower frequency of over-drainage symptoms compared to patients whose shunts had no valve [22]. Historically, lumboperitoneal shunting was performed by implanting a single tube with the proximal end in the lumbar CSF space and the distal end intraperitoneally. Tonsillar herniation was a common sequel following these shunts [2]. Spetzler et al. and others introduced LPS with a valve system [11, 23]. Valve types used for LPS can be subdivided into three types: 1 conventional differential pressure valves with a fixed opening pressure, 2 adjustable devices, enabling noninvasive percutaneous change of the opening pressure, and 3 hydrostatic valves that take into account the patient posture and include flow-restricting devices that change their flow regulation in a gradual way (analog type of valves e.g., Miethke's ShuntAssistant) or have an abrupt change of regulation status (e.g., as with the M-DSV). Many of these valves are not subject to reliable quality control [24]. In their detailed evaluation of shunt valves, Czosnyka et al. concluded that the actual in vivo behavior of the majority of valves currently available may not exactly match the manufacturer s product information. Significant problems encountered by Czosnyka and colleagues included over-drainage, sensitivity of CSF flow to body posture, blockage caused by subcutaneous pressure, and changes in settings related to external magnetic fields [2527]. Czosnyka et al. reported that the over-drainage rate might be reduced in Medtronic PS Medical LPS because of the very high hydrodynamic resistance of the thin tube (internal diameter of 0.8 mm, compared with

1.2 mm for most distal drains). On the other hand, such high resistance may potentially cause the shunt to underdrain in horizontal body positions [27]. Various additional methods have been used to avoid and manage CSF over-drainage, including upgrading the valve to a higher-pressure valve, adding an anti-siphon device, and using a programmable valve, all with inconsistent results [35, 28, 29]. Upgrading the valve pressure setting to overcome over-drainage may lead to increased resistance, especially in the supine position, and may lead to symptoms of under-drainage. Wang et al. reported that among the74 patients with LPS, 11 had symptoms of over-drainage. Seven of these patients had a valveless system, and four had a HV valve. In nine of these 11 patients, symptoms resolved after a valve was inserted or after their valves were set to a higher pressure [5]. The Integra HV valve (Integra LifeSciences, Plainsboro, NJ) utilized in that series was introduced in the 1990s for LPS. The Integra HV incorporated two different valves to allow for control of CSF flow when a patient is in either upright or supine position. In addition, an antechamber is available for access to the LPS. Chang et al. in their series of LPS with Codman Hakim programmable valves for NPH observed over-drainage symptoms in five of 32 patients, but they recovered after increasing the valve pressure. According to Chang et al., the major advantage in the use of programmable valve is the ability to modify the pressure and thus manage overdrainage or under-drainage noninvasively. Thus, inclusion of the Codman Hakim programmable valve in the LPS may avoid the need for a second operation in which a different pressure valve is implanted [3]. Nadkarni et al. placed a ventricular access device (VAD) and an LPS using a Codman Hakim programmable shunt with a SIPHONGUARD (Codman Corp.). The VAD was meant for ICP measurement, and the shunt also had a flowlimiting device, the (flow-restricting device [30]). This add-on device increases resistance linearly with high CSF flow and may therefore prevent over-drainage [4]. A significant disadvantage of programmable valves is finding the correct pressure as the rate of CSF production and the pressureflow curve are not precisely known in individual patients. Also, the programming may be inaccurate especially if the patient is obese, as is often the case for patients with PTC. Additionally, since the main problem for pressure valves is maintaining sufficient CSF drainage while the patient is in supine, sitting, and standing positions, they may reduce but cannot exclude overdrainage [31]. In addition, valve pressure setting may be altered even by low magnetic fields [32]. The additional placement of a VAD requires an additional procedure (usually stereotaxy-based) and entails the potential morbidity of an invasive cortical procedure and infection. Zemack


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and Romner conducted a cost analysis of programmable valves and concluded that the increased cost cannot be adequately justified with the current evidence of complications associated with these valves [32]. In principle, siphoning per se should not significantly affect an LPS due to the comparable heights of the proximal and distal tips of the shunt system. However, the pressure at the proximal end of the valve reflects the hydrostatic pressure of a fluid-filled column (between the intracranial compartment and the spinal subarachnoid space upstream from the tip of the intrathecal catheter). As the valve is a pressure-regulated system, the elevated pressure differential across the valve during upright positions increases the flow and CSF drainage rates as compared to that during a supine position, hence the high rate of over-drainage in LPS. The efficacy of an anti-siphon device to counter overdrainage in LPS is questionable [30]. The reason is, as discussed above, that true siphoning may not have a role in the CSF dynamics of an LPS. Also, susceptibility to subcutaneous pressures in general and during routine activity in particular raises questions over their efficacy. Hence, valves with anti-siphon devices (such as the Delta valves) probably have a limited role to play in preventing LPS over-drainage. The concept of gravitational shunts has existed since 1970s and has been found to have encouraging results in avoiding posture-related over-drainage in adult and childhood hydrocephalus [3335]. In 1975, Hakim presented the Hakim Lumbar HV valvethe first technically mature gravitational shunt. The first concept of the switcher type of gravitational valve was introduced with Marions Sophysa AS valve in 1983. This valve too was not well accepted. The first valve regulation for HV change was introduced by Hakim-Cordis in the 1980s. These valves did not stand the test of time and are mostly no longer available [31]. The M-DSV system is also a type of kind of a HV switcher type of valve. As described above in the subsection The M-DSV Technology under section Materials and Methods, the valve resistance changes depending on the patient position, toggling between a low-resistance opening pressure while in supine position and a highresistance opening pressure while in upright position. Several authors found clear reduction in over-drainage among patients with adult hydrocephalus who were treated by VPS with M-DSV [1, 610]. Mier et al. in their series of M-DSV for 128 patients with NPH treated by VPS with MDSV found an over-drainage rate of 2% [6]. Another study by the same author compared different valves, reporting an over-drainage rate of about 6% with Cordis standard valves, 16% with Cordis-Orbis-Sigma valves, and 2% with M-DSV [36]. Tsunoda et al. in their series of VPS with M-DSV for

101 patients with adult hydrocephalus reported only three patients with over-drainage. Six patients, in this series, experienced under-drainage (importantly all bedridden patients) [9]. In our series, four patients with prior LPS (various valves including two with Delta valves) presented with symptoms of over-drainage. In view of the prior published results showing the advantage of M-DSV in VPS for various hydrocephalic pathologies in adults, we opted to place the M-DSV in these LPS patients with apparent success. In the fifth patient, by using an M-DSV, we seem to have averted the possible complication of over-drainage which elderly patients are prone to [37]. Although in our small series we seem to have overcome the issue of over-drainage in all patients using the same lower-pressure setting (10 cm H2O), over-drainage may still occur in some patients. In such cases, an M-DSV with a higher low-pressure setting could be used. Unlike most programmable valves, opening pressures of the M-DSV valves are not affected by magnetic field, and the titanium casing makes it resistant to changes in subcutaneous pressure [38, 39]. The M-DSV also has an antechamber that can be used for pressure measurement, fluid aspiration for analysis, and ruling out proximal malfunction. Also, unlike other flow-restricting devices (where the requirement for the device to be placed parallel to the body axis for effective action may be inconvenient in cases of LPS), the M-DSV designed for LPS can conveniently be interposed in line with the shunt tubing. Unlike the Cordis HV valve and the Chabbra valve, the force exerted by CSF flow in the M-DSV is downward on the gravity-propelled ball whenever the patient is in the upright position, supporting the closing mechanism of the tantalum ball, as opposed to the other two valves where the CSF flows against the gravity-activated closing mechanism of the balls. Therefore, in the M-DSV, the forces acting upon the tantalum ball closing the lowpressure chamber become stronger with rising ICP and/or hydrostatic pressure. Thus, the danger that the closing mechanism will be influenced by normal activities of daily life such as walking, running, or other valsalva maneuvers is much lower with the M-DSV than with the other valves. Simulation of such normal daily activities in vivo proved the superiority of the closing mechanism of the tantalum ball in the M-DSV over those in the Cordis HV valve and the Chabbra valve [39]. Conventional radiographs allow checking of the graduation and position of the MDSV and can also test the tantalum ball movements [39]. While hydrostatic valves theoretically have a higher risk of clogging [40, 41], the M-DSV seems to have a lower risk of clogging due to a larger diaphragm surface area, and hence may maintain CSF flow irrespective of its composition [35, 39].

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One possible disadvantage of the M-DSV valves is the fixed pressure settings. Any change of settings requires an operative intervention. Although our patients had good outcomes, shunt revisions to implement necessary pressure changes are a definite possibility. Tsunado et al. in their study on treatment of adult hydrocephalus with M-DSV had a rate of 7.5% shunt revisions due to under-drainage [9]. The M-DSV has been proven to establish a physiological CSF diversion irrespective of patient posture and CSF composition in adult hydrocephalus [79, 39]. Our attempt to exhibit the same for LPS seems to hold promise. There still remains the need for larger studies as well as longer follow-up.

Conclusions Using the M-DSV in LPS may balance the need for effective CSF drainage on one hand while preventing over-drainage on the other. However, controlled studies are indispensable, and further evaluation of this valve, both as a primary choice for LPS and in revisions for over-drainage, should be sought. Our early experience highlights the advantages of this valve for patients with LPS.

Disclosure The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. None of the authors have received any financial support for the article from any organization.

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