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Medtronic Neurologic Technologies
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Anatomy and Physiology
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Cerebrospinal Fluid (CSF)
• CSF is formed by the choroid plexus in the brain ventricles
• CSF is absorbed by the arachnoid villi
• Circulatory system – CSF production is
balanced by arachnoid villi absorption
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Cerebrospinal Fluid (CSF)
CSF is transferred by the arachnoid villi to the sagittal sinus where it exits the body by way of the venous system
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CSF Basic Statistics
• The average person
produces 500 ml of
CSF a day, or roughly a
pint
• CSF is produces by the
choroid plexus at a rate
of 20-25 ml/hr
• CSF serves to “cushion”
the brain, and to
provide some basic
nutrients
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Hydrocephalus
• Greek: “Water-on-the-Head”
– Hydro – Water
– Kephale – Head
• Types of Hydrocephalus
– Obstructive
– Communicating
– NPH
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Hydrocephalus
• “Non- Communicating/Obstructive:
60% cases
– CSF flow path blockage
• Tumor
• Spina Bifida
• Aqueductal Stenosis
– Congenital Defect
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Hydrocephalus
• Communicating: 40%
cases
– Over-production of CSF
• Choroid Plexus Palpiloma
– Under-absorption of CSF
• Subarachnoid Hemorrhage
• Intraventricular Hemorrhage
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Pediatric Hydrocephalus
Sunset Eyes
Enlarged Head
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Adult On-Set Hydrocephalus Normal Pressure Hydrocephalus (NPH)
• Definition: A hydrocephalus disease of the elderly ( > 60 years) characterized by a classic triad of symptoms: Dementia, Gait Disturbance, Incontinence.
• The triad of symptoms is called the Hakim-Adams Triad.
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Feature Early Stage Late Stage End Stage
Gait Disturbance Falling Spells
Off-Balance
Slow Shuffling Gait
Small Steps
Broad-
Based Gait
Unable to
Walk
Bedridden
Mental
Deterioration
Apathy
Inattention
Short Memory
Deficits
Akinetic
Mutism
Bright Moments Decreased speed
of complex
information
processing.
Incontinence Urge Incontinence Loss of Sphincter
Control
Fecal
Incontinence
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Normal Pressure Hydrocephalus (NPH) • Since the symptoms are often associated with
aging or other aging diseases, NPH is often
misdiagnosed. – Senility, Alzheimer's, Parkinson’s
• Incidence: 5% of all dementia cases*
• Numbers will increase with improved
healthcare and extended longevity
• Treatment decisions are complex due to co-
morbidities in the elderly population
*NPH Guidelines, Neurosurgery, Marmarou et al, 2005
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Normal Pressure Hydrocephalus (NPH)
• Idiopathic – Unknown origin
• Secondary to: – Head injury
– Cranial surgery
– Subarachnoid hemorrhage
– Meningitis or infection
– Tumors and cysts
– Subdural hematomas
• The link between the pathophysiology and clinical presentation is unclear – Change in brain compliance.
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NPH Diagnosis
• Primary Care Physician – Referral
• Neurologist - Diagnosis
• Neurosurgeon – Shunt Implantation
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NPH Diagnosis
• Preliminary Diagnosis
– Duration and sequence
of symptoms
– CT or MRI scan
– Neuropsychological
Tests
– ICP Measurements
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NPH
Prognostic Tests
• Responsiveness to
CSF removal – Lumbar CSF Tap Test
• 50% Specificity
– External Lumbar
Drainage (2-3 days)
• 90% Specificity
– Lumbar Infusion Study
(measures CSF
absorptive capacity)
• 80% Specificity
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Hydrocephalus – Final Facts
• Incidence:
– 1/1000 babies is born hydrocephalic
• Brain hemorrhage, brain defect, spina bifida
– 1/10,000 adults will have late onset
hydrocephalus
• NPH, trauma, tumor development, stroke,
aneurysm rupture
• Life-Long Condition
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Hydrocephalus – Final Facts
Geography Procedures/Year
United States 42,000
Europe 25,000
World Wide 164,000
Untreated 600,000
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Hydrocephalus Treatment
• Shunting
– Differential Pressure
Valves
– Siphon Control
Devices
– Adjustable Valves
• Third Ventriculostomy
– Endoscopes
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The Standard of Care - Shunt Ventricular
(proximal) Catheter
Valve
Distal Catheter Ventriculoatrial (VA) Shunt: 5% Ventriculoperitoneal (VP) Shunt: 95%
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Shunt Surgery
• Subcutaneous implant (under the skin) – Skin flap
– 3-6 mm burr hole
– Insertion of ventricular catheter based on anatomical landmarks
– Tunneling of distal catheter
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3rd Ventriculostomy
• Fenestration through the floor of the 3rd ventricle into the basal cistern
• Obstructive hydrocephalus – 2 years and older
• “Internal Shunt” – Risk of fenestration
closure
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Hydrocephalus Shunts
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CSF-Flow Control Valves
Regular Size Older Children &
Adults
Small Size Infants &
Young Children
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CSF-Flow Control Valve
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Valve Mechanism Polypropylene (plastic) Base
Silicone Membrane (Diaphragm
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Pressure/Flow Ranges
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CSF-Flow Control Valves
• Variation in Sizes
– Pediatric Models
– Adult Models
• Surgical Technique
– Burr Hole Styles
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Shunting Complications
• 40% of all shunts fail
within the first post-
operative year
– Infection
– CSF Overdrainage
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CSF Overdrainage
Normal Ventricles Collapsed/Slit Ventricles
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CSF Overdrainage
• Chronic obstruction of
the proximal catheter tip
by choroid plexus
• Proximal obstruction
accounts for 30% of all
shunt failures
Choroid Plexus
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CSF Overdrainage
• Subdural Collections
– Subdural Hygroma
caused by disruption of
the arachnoid
– Subdural Hematoma
caused by stretched
subarachnoid blood
vessels
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CSF Overdrainage
• Craniostenosis
– Premature closing of
the cranial sutures
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CSF Overdrainage
• Slit Ventricle Syndrome – Transient intracranial
hypotension which occurs in patients with a functioning shunt and slit-like ventricles
• Orthostatic Hypotension – Postural headaches and
nausea
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Hydrostatic Shunt Pressures
• When the patient is reclined, the valve is allowed to react to pressure at the shunt inlet, due to the absence of any distal catheter pressure.
• When upright, gravity acts on the fluid filled distal catheter creating a siphon affect.
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Why doesn’t the valve stop it?
• In the upright position, a differential pressure valve doesn’t know the difference between “positive” pressure from the ventricles “pushing” the valve open, or “siphoning” from the distal catheter “pulling” the valve open.
• The valve mechanism responds to whatever hydrostatic force is the strongest – which is typically siphoning.
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Delta® Valve Includes Delta Chamber for Overdrainage
Protection
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Delta® Chamber for Siphon Control
Inlet area affected by Positive IVP
Outlet affected by distal siphoning
Detail of the siphon regulating mechanism. The ratio of the
hydrodynamic leverage inlet area to the outlet area is greater than 20:1.
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Delta® Valve Features
• The 20:1 hydrodynamic leverage ratio allows the patient to maintain ICP within a physiologic range, regardless of patient posture.
• Normally closed Delta Chamber diaphragms, respond to upstream positive hydrostatic pressure, but remain closed in the presence of downstream negative hydrostatic pressure.
• Delta Chamber diaphragms are recessed below a protective polypropylene outer ring to minimize the risk of diaphragm compression from overlying tissue.
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Strata® ; The Adjustable Delta® Valve
Delta Chamber
Adjustable Valve Mechanism
Valve Body
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Strata® Valve Mechanism Ruby Ball & Cone
Rotor with Magnet
Base Platforms
Base Platform Stops
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Strata® Valve Mechanism Cap
Seal
Guide Ring
Rotor Retention
Spring Ball
Pressure/Flow
Spring
Magnetic Rotor
Valve Base
With 5 Concentric
Platforms
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Strata® Pressure/Flow Ranges
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Strata® Adjustment Tools
Verification Tool Adjustment Tool Locator Tool
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Strata® Valve Adjustments
Pre-operative Post-Operative
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StrataVariusTM
• Handheld instrument
designed to be
ambidextrous
• Battery powered device (2-
AA)
– 100 uses
– Power-down after 3
minutes of idle time
• LCD readout screen
• Portal for valve palpation
and magnetic adjustment
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Strata® Valve X-Ray
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Medtronic NT Shunt Products
• CSF-Flow Control Valves - Provide a set resistance to flow, but do not manage negative hydrostatic pressure.
• Delta® Valves - Include overdrainage protection to minimize the risk of slit ventricles and associated complications.
• Strata® Valves - Can be non-invasively adjusted to 5 different pressure settings.
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Ventricular Reservoirs & Ports
• Commonly called
“Ommaya Reservoirs*”
– Pediatric Sizes
– Adult Sizes
– Burr Hole
*Ommaya® is a registered
trademark of Integra NeuroCare
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Indications for Use
1) Administration of chemotherapy for CNS
neoplasms including: carcinomatous
meningitis, CNS lyphoma or luekemia
2) Fluid aspiration from a chronic tumor cyst
that is resistant to therapy
3) Chronic removal of CSF from infants with
intraventricular hemorrhage
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Ventricular Reservoirs
• Silicone dome is thick
• Tolerate 130 punctures using a 25G or smaller non-coring needle. – B-D Needle 305122
• Plastic needle guard to prevent needle penetration.
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Ventricular Port
• Tolerate a minimum of 800 punctures using a 22G Huber needle
• Raised septum ring design provides a reference point for needle penetration
• Available in 16 mm and 30 mm sizes
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Volume of Reservoirs and Ports
• The product instructions detail the volume
capacity of all reservoirs & ports.
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Reservoir Puncture
• Insert recommended needle size (e.g. 25G) into the reservoir and slowly withdraw a sample of CSF.
Insert the small needle into the reservoir at an oblique angle. Inserting at an angle allows for the silicone at the hole site to reseal.
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Medtronic Neurologic Technologies
Working to Restore Full Health and Life