Codman Hakim Programmable Valve Research Articles

Maladjustment of pressure settings of a programmable shunt valve by electromagnetic door locks in Forensic Psychiatry – a case report

IntroductionMaladjustments and failures of programmable ventriculo-peritoneal shunts have been reported in patients encountering powerful electromagnetic fields, e. g. MRI.We describe the case of a 53-year old man treated for hydrocephalus with a programmable Codman-Hakim shunt valve. During his hospitalization in Forensic Psychiatry, the patient’s valve pressure setting changed randomly despite frequent reprogramming and surveillance.ObjectivesMaladjustments and failures of programmable ventriculo-peritoneal shunts have been reported in cases in which patients have encountered powerful electromagnetic fields, e.g., MRI. Through a case, this study shows easy maladjustment of a Codman-Hakim programmable valve also by small magnetic fields from everyday life.MethodsA 53-year old man presented with periventricular hydrocephalus due to aqueductal stenosis. The patient was treated with a left ventriculo-peritoneal Codman-Hakim programmable shunt valve. During his hospitalization in Forensic Psychiatry, the patient’s valve pressure setting changed randomly, presumably by walking through electromagnetically controlled doors of a hospital ward. With a test dummy, changes in pressure settings were tracked.ResultsBoth - pressure settings of the patient’s Codman-Hakim programmable valve as well as pressure settings of a new valve - were unwantedly modified simply by walking through standard doors in a hospital ward.ConclusionsThus already weak magnetic fields (< 200 mT) might cause changes in the pressure settings of programmable shunt valves and therefore lead to maladjustment. Patients should be informed and pay attention to using everyday life’s devices, like rod magnets or mobile phones.DisclosureNo significant relationships.

P 68 Unintentional maladjustment of a shunt valve due to electromagnetic door locks – A case report

Normal-pressure hydrocephalus is caused by dilatation of the internal cerebrospinal fluid spaces at normal intracranial pressure. The resulting progressive accumulation of CSF in the brain space can cause permanent damage and, if left untreated, complete loss of brain tissue [2, 4]. The standard treatment for hydrocephalus in children and adults is the implantation of a ventriculo-peritoneal shunt (VP shunt). Most of the currently used shunt systems have a valve to control pressure and drain CSF if necessary [4]. In recent years, malfunction of programmable VP shunts has been reported in patients exposed to strong electromagnetic fields, such as those generated during magnetic resonance imaging (MRI) [1, 3]. However, little is known about the effects of weak magnetic fields on VP shunts. We present the case of a 53 -year-old forensic psychiatric patient in whom the pressure setting of an implanted Codman-Hakim programmable shunt valve changed during passage through various ward doors, leading to the onset of psychiatric symptoms. During the inpatient stay, the valve's pressure setting changed at least six times randomly despite frequent reprogramming and monitoring. References 1 Akbar M, Aschoff A, Georgi JC, Nennig E, Heiland S, Abel R, Stippich C (2010) Adjustable Cerebrospinal Fluid Shunt Valves in 3.0-Tesla MRI: a Phantom Study using Explanted Devices. Rofo 182(7):594-602 2 Kahle KT, Kulkarni AV, Limbrick DD, Warf BC (2016) Hydrocephalus in children. Lancet 387(10020):788–799 3 Mirzayan MJ, Klinge PM, Samii M, Goetz F, Krauss JK (2012) MRI safety of a programmable shunt assistant at 3 and 7 Tesla. Br J Neurosurg 26(3):397-400 4 Portillo Medina SA, Franco JVA, Ciapponi A, Garotte V, Vietto V (2017) Ventriculo-peritoneal shunting devices for hydrocephalus. Cochrane Database Syst Rev. 2017(7): CD012726 Figure 1. Scetch of a Codman-Hakim shunt valve. Figure 2. Image of a Codman-Hakim VP shunt before and after passing a door.

Lumbo-Peritoneal Shunt for Patients with Idiopathic Normal Pressure Hydrocephalus:Surgical Technique

The SINPHONI-2 study(a group of Japanese prospective multicenter cohort studies on the treatment of idiopathic normal pressure hydrocephalus[iNPH])showed the safety and efficacy of lumboperitoneal(L-P)shunt surgery for iNPH. A total of 660 probable iNPH patients underwent L-P shunt surgery at our NPH center between April 2009 and March 2020(age: 77.3 ± 6.2 years). Our surgical technique includes 1)general anesthesia, 2)use of the original drape, 3)upward insertion of the spinal tube through L2/3 via a paramedian puncture in patients with highly deformed lumbar spines, 4)posterior placement of a Codman Hakim programmable valve with SiphonguardTM, 5)inclination of the table at a 35° angle without position change and re-sterilization, 6)laparotomy via rectal muscle splitting, and 7)oblique maneuvering the peritoneal tube from the upper lateral to the lower medial sector. During the first year after surgery, postoperative complications occurred in 14 of 172 patients (8.1%), including four patients with chronic subdural hematoma requiring evacuation (2.3%), three with spinal tube occlusion (1.7%), three with migration of the spinal tube, two with lower-limb numbness (1.2%), and two with abdominal tube occlusion. Our L-P shunt procedure seems to be generally acceptable considering the low number of complications.

Maladjustment of pressure settings of a Codman-Hakim programmable shunt valve by electromagnetic door locks – a case report

Maladjustment of pressure settings of a Codman-Hakim programmable shunt valve by electromagnetic door locks – a case report

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

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.

Programming jammed Codman Hakim programmable valves: study of an explanted valve and successful programming in a patient

Malfunction of a Codman Hakim programmable valve due to jamming of its programmable component may necessitate shunt revision. The authors report a method for programming jammed Codman Hakim programmable valves by using a Strata II magnet and additional neodymium magnets. The programming method was derived after studying a jammed valve in the laboratory that was explanted from an 10-year-old boy with a history of fourth ventricle ependymoma. Programming the explanted valve with a Codman programmer failed, but rotating a Strata II magnet above the valve resulted in rotation of the spiral cam in the valve. It was found that the Strata II magnet could be used to program the jammed valve by rotating the magnet 90° or multiples of 90° above the valve. The strength of the magnetic field of the Strata II magnet was able to be increased by putting neodymium magnets on it. The programming method was then successfully used in a patient with a jammed Codman Hakim programmable valve. After successful programming using this method, clinical and radiological follow-up of the patient was advised.

Lumbosubarachnoid–Lumboepidural Shunting in Patients With Idiopathic Normal-Pressure Hydrocephalus: Surgical Procedures and Follow-up Study of Five Cases

The objective of the study is to introduce the surgical procedure of the lumbosubarachnoid-lumboepidural (L-L) shunting performed as treatment for idiopathic normal-pressure hydrocephalus (iNPH) and its follow-up. The subjects were five patients with probable iNPH (aged 78-85 years; mean age 81 years; four males and one female) who were judged to be at high risk from general or lumbar anesthesia due to their systemic complications and age. The L-L shunt operation was performed for all the patients under local anesthesia using Codman-Hakim Programmable Valve(®) (Codman & Shurtleff, Inc., Raynham, Massachusetts, USA). The initial pressure for all patients was set at 8 cmH2O. The evaluation of shunt efficacy and the lumbar epidural space cerebrospinal fluid (CSF) absorption test (injection of contrast media into epidural space) were performed both on the operation day and during follow-up period (9-12 months). The shunt operation was judged to be effective in four out of five patients (regarded as shunt responders), whereas no improvement in symptoms was seen in one patient (regarded as shunt nonresponder) where the shunting had no effect after the initial pressure was changed to 4 cmH2O. The lumbar epidural space CSF absorption test both on the operation day and during the follow-up period confirmed absorption in all patients. The L-L shunting is useful for patients with probable iNPH who are at high risk from general or lumbar anesthesia due to their systemic complications and age. CSF was continuously absorbed in the lumbar epidural space during postoperative follow-up period. A longer follow-up is required to establish this surgical procedure.

In vitro experiment for verification of the tandem shunt valve system: a novel method for treating hydrocephalus by flexibly controlling cerebrospinal fluid flow and intracranial pressure

The CSF shunt valve is a medical device whose main function is to regulate intracranial pressure and drain excess CSF. The authors have developed a new therapeutic method for treating hydrocephalus, namely the tandem shunt valve system, which has the potential of flexibly controlling the CSF flow rate and intracranial pressure in patients. The properties of the tandem system were verified by performing in vitro experiments. An in vitro system with a manometer was built to measure pressure and flow rates of water in open systems using the Codman Hakim Programmable Valve and the Strata adjustable pressure programmable valve. A single valve and 2 single shunt valves connected in series (the tandem shunt valve system) were connected to the manometer to check the final pressure. Conventional single shunt valve systems require valve pressures to be set higher to slow down the CSF flow rate, which inevitably results in a higher final pressure. On the other hand, the tandem shunt valve system uses the combination of 2 valves to slow the CSF flow rate without increasing the final pressure. The authors succeeded in experimentally demonstrating in vitro results of tandem systems and their effectiveness by applying a model to show that the valve with the higher pressure setting determined the final pressure of the entire system and the flow rate became slower than single shunt valve systems.

Assessment of a Quick Reference Table Algorithm for Determining Initial Postoperative Pressure Settings of Programmable Pressure Valves in Patients With Idiopathic Normal Pressure Hydrocephalus

Management of overdrainage complications in shunted patients with idiopathic normal pressure hydrocephalus (INPH) remains a difficult task despite the use of programmable pressure valves. To assess the usefulness of a quick reference table (QRT) algorithm for achieving a suitable initial programmable pressure valve setting in INPH patients who participated in the Study for INPH on Neurological Improvement (SINPHONI). One hundred registered patients diagnosed with probable INPH were treated with ventriculoperitoneal shunts using Codman-Hakim programmable valves (CHPVs). In this series, the initial CHPV setting was decided prospectively according to the QRT algorithm. Shunt effectiveness, complications, and the number of CHPV readjustments during follow-up periods were investigated. Eighty patients were considered better than shunt responders (more than 1 point improvement in modified Rankin scale at any follow-up period). Readjustments of CHPVs within 3 months after treatment with ventriculoperitoneal shunt were performed 56 times in 44 cases (44%, 0.56 times/patient). Low-pressure headache occurred in 9 patients, all of whom improved by readjustment alone. Nontraumatic subdural fluid collections and chronic subdural hematomas occurred in 15 cases (15%); however, most of the cases were subclinical and improved after CHPV readjustments alone. Burr hole irrigation was necessary in only 1 case. Use of the QRT algorithm was associated with a decrease in postoperative CHPV readjustments and serious overdrainage complications during the follow-up period. The QRT algorithm is an easy, safe, and effective method for determining the initial CHPV pressure setting in INPH patients.

Programmable Shunt Valves: In Vitro Assessment of Safety of the Magnetic Field Generated by a Portable Game Machine

Cerebrospinal fluid (CSF) shunts are frequently used to treat hydrocephalus. The use of a programmable shunt valve allows physicians to easily change the opening pressure. Since patients with adjustable CSF shunt valves may use portable game machines, the permanent magnets in these machines may alter the shunt valve programmed settings or permanently damage the device. This study investigated the risk of unintentional valve adjustment associated with the use of game machines in patients with programmable CSF shunt valves. Four adjustable valves from 4 different manufacturers, Sophysa Polaris model SPV (Polaris valve), Miethke proGAV (proGAV), Codman Hakim programmable valve (CHPV), and Strata II small valve (Strata valve), were evaluated. Magnetic field interactions were determined using the portable game machine, Nintendo DS Lite (DS). The maximum distance between the valve and the DS that affected the valve pressure setting was measured by x-ray cinematography. The Polaris valve and proGAV were immune to unintentional reprogramming by the DS. However, the settings of the CHPV and Strata valves were randomly altered by the DS. Patients with an implanted shunt valve should be made aware of the risks posed by the magnetic fields associated with portable game machines and commonly used home electronics.

A Nonradiographic System for Assessing Pressure for the Codman-Hakim Programmable Valve

The Codman-Hakim Programmable Valve is widely used in shunting hydrocephalus and other conditions. To establish an accurate valve verification system for the Codman-Hakim programmable valve that does not require radiographic exposure. Prospective clinical trial tested a new valve verification system at 9 research sites. The Valve Programming and Verification System allowed us to establish the valve setting in 62% of subjects with a programmable valve. The Valve Programming and Verification System avoids radiation exposure, is cost-effective, and time efficient for the patient and provider. In approximately one third of subjects, those in whom "adjustment complete" is not achieved, cranial radiographs are still needed.

Improved Outcome in Shunted iNPH with a Combination of a Codman Hakim Programmable Valve and an Aesculap-Miethke ShuntAssistant

Low pressure valves with ventriculoperitoneal shunts have been proven to lead to good outcomes in the treatment of idiopathic normal pressure hydrocephalus. However, overdrainage complications are often seen with low opening pressures. Efforts have been made to obtain good outcomes without overdrainage complications by decreasing the hydrostatic pressure component using special valve constructions. The aim of this study was to ascertain whether it is possible to optimise outcome with the implantation of both an adjustable valve and a gravitational unit. Between July 2003 and July 2006, 42 patients underwent ventriculoperitoneal shunt surgery with a Codman Hakim programmable valve (Codman, Johnson & Johnson, Raynham, USA) and a Miethke ShuntAssistant (Miethke Gmbh, Potsdam, Germany). These patients were followed up for a period between 2 years (35 patients) and 4 years (18 patients) after surgery. The systematic re-programming of the valves from 100 mmH(2)O to 70 mmH(2)O and then to 50 mmH(2)O after 3 months allowed the brain to adapt to the implanted valve without the complication of overdrainage. The responder rates were 86% after two years and 83% after four years. Overdrainage was seen in 3% of the cases, mechanical complications occurred in 6%. Our results indicate that the combination of a Codman Hakim programmable valve with a Miethke ShuntAssistant could improve outcomes in shunted iNPH. This finding has yet to be proven in a larger, prospective randomized trial.

Overdrainage of cerebrospinal fluid caused by detachment of the pressure control cam in a programmable valve after 3-tesla magnetic resonance imaging

The authors report a rare case of overdrainage of the CSF caused by the malfunction of a Codman-Hakim programmable valve (CHPV) following a 3-T MR imaging procedure. Nine years ago this 72-year-old woman underwent ventriculoperitoneal shunt placement with a CHPV system for hydrocephalus due to subarachnoid hemorrhage. The postoperative course was uneventful and the system functioned well. A radiograph obtained immediately after 3-T MR imaging revealed that the pressure control cam in the valve system was detached from the base plate. Intracranial hypotension syndrome occurred several hours after the MR imaging study, and a CT scan revealed a decrease in ventricle size. A revision of the system promptly resolved the symptoms, and a postoperative CT scan revealed that the ventricle size was restored to normal. Examination of the extracted valve showed a Y-shaped crack in the plastic housing as well as detachment of the white marker and cam from the base plate. A reduction in the power of the flat spring to press the valve ball led to CSF overdrainage because of a loss of support by the cam. Because the patient had incurred no head injury during the day and radiographic studies of the system 5 years previously had shown detachment of the white marker, damage to the system might have been caused by a past impact. These facts may indicate that the antimagnetic performance of the system could have decreased due to a previous impact and that the strong magnetic force in a 3-T MR imaging environment might have caused detachment of the cam.

Lumboperitoneal shunt placement using computed tomography and fluoroscopy in conscious patients

The authors have developed a minimally invasive lumboperitoneal shunt placement procedure conducted after administration of a local anesthetic. The procedure involves placing a guide wire and a peel-away sheath under fluoroscopic and CT guidance. Between June 2004 and August 2006, 40 patients (21 men and 19 women; mean age 72.5 years [range 33-86 years]) underwent surgery. A Codman Hakim programmable valve system (82-3844, Codman & Shurtleff, Inc.) was used for the procedure. The mean operating time was 53 minutes, and 7 patients (17.5%) developed shunt dysfunction complications. These complications comprised an infected shunt valve in 2 patients, postoperative lower-limb pain in 1 patient, and shunt obstruction (caused by debris and hemorrhage) at the ventral and lumbar ends in 2 patients each. This procedure is less invasive than conventional lumboperitoneal shunt insertion and could be performed as an outpatient surgery for treatment of idiopathic normal-pressure hydrocephalus.

Are adjustable valves effective? Data from the UK Shunt Registry

Background Adjustable (often-called programmable) CSF valves have been developed by several manufacturers. These valves are more expensive, but have an advantage in that the operating pressure of the valve can be altered by the use of an external magnet as a simple procedure. The proportion of these valves used in the UK and Ireland has increased from 4.9% in 2000 to 22.4% in 2006. We have used data collected by the UK Shunt Registry to assess the effectiveness of these valves in reducing valve replacement for under and over-drainage using a case-control design. Materials and methods The UK Shunt Registry contains data on nearly 30,000 CSF shunt-related procedures. Our data suggests that primary factors involved in shunt revision are patient age, diagnosis and the number of revisions a patient has had. Procedures were identified where either a Medtronic Strata Valve or Codman Hakim Programmable Valve was used. Of these 1,389 had an accurate diagnosis and age entered and we were able to determine the exact number of shunt revisions. A database search was performed for procedures matched for patient age, diagnosis and revision status but using Medtronic or Codman fixed-pressure valves. Matches were found for 943 procedures.

Magnetically programmable shunt valve: MRI at 3-Tesla

A magnetically programmable cerebrospinal fluid (CSF) shunt valve (Codman Hakim Programmable Valve, Codman, a Johnson & Johnson Company, Raynham, MA) was assessed for magnetic field interactions, heating, artifacts and functional changes at 3-Tesla. The programmable valve showed minor magnetic field interactions and heating (+0.4 degrees C). Artifacts were relatively large in relation to the size and shape of this implant and, as such, may create a problem if the area of interest is in proximity to this implant. While multiple exposures and various magnetic resonance imaging (MRI) conditions at 3-Tesla changed the settings of some valves (i.e., reprogramming was needed), the function of the programmable valve was not permanently affected. Therefore, this magnetically programmable CSF shunt valve is acceptable for a patient undergoing MRI at 3-Tesla or less when specific safety guidelines are followed, including resetting the valve, as needed.

Confirmation of the Initial Pressure Setting in Codman-Hakim Programmable Valves Under Magnification -Technical Note-

Codman-Hakim programmable valves allow neurosurgeons to adjust the opening pressure to the patient's particular clinical needs. However, the pressure control cam is extremely small, so identification of the pressure indicator and its operation is somewhat difficult when initially setting the opening pressure before implantation. We employed a commercial loupe on the program transmitter unit to sufficiently enlarge the view of the cam for clear identification. We recommend that the manufacturer to incorporate a loupe to provide a more sophisticated product.

Disparity between adjusted and actual opening cerebrospinal fluid pressure in a patient with the Codman Hakim programmable valve: occult form of shunt failure due to head banging

Although the Codman Hakim programmable valve (CHPV) system is popular, several problems arising from its design have been described. The authors report an additional cause of shunt failure associated with the use of the CHPV system. A 7-year-old girl who had previously undergone placement of a ventriculoperitoneal shunt with the CHPV system was admitted in a comatose state. Radiography did not demonstrate any breakage or change in the opening pressure of the valve. Manual pumping of the valve resulted in neurological improvement and shrinkage of the girl's ventricles. However, ventriculomegaly was again observed several hours later, and an emergency valve revision was performed. The manufacturer's examination of the extracted valve revealed a crack on the surface of the hard plastic housing covering the valve chamber, which appeared to be suggestive of some type of blunt trauma. In addition, the flat spring that transmitted resistance from the pressure control cam to the valve ball was deformed in such a manner that it caused excessive pressure against the valve ball. Because of this deformity, the actual opening pressure in this patient had reached a maximum level of 226 mm H2O instead of the adjusted pressure of 60 mm H2O. In patients with the CHPV system whose medical history is difficult to ascertain, the possibility of damage to the valve spring and the need for a prompt revision surgery should be considered. The authors conclude that placement of the CHPV system may be contraindicated in patients with a known habit of head banging.

The Programmable Adult Codman Hakim Valve is Useful Even in Very Small Children with Hydrocephalus

Ventriculo-peritoneal shunting is the most commonly used method for the treatment of paediatric hydrocephalus. The programmable valve with the ability to adjust the opening pressure non-invasively has made it easier to find exactly the right opening pressure for each child and reduce the risk of over- or under-drainage. The aim of this investigation was to study our clinical experience with the adult Codman Hakim programmable valve in children, with reference to complications and economic impact. A seven-year retrospective study of 122 hydrocephalic children (aged from children born prematurely to 15 years old) shunted with the adult Codman Hakim programmable valve was performed. The programmable valve was the first shunt in 76 children and in 14 after prior ventricular drainage. The remaining 46 had different non-programmable systems as their first shunt. The most common reason for changing to a programmable valve was over-drainage. With the programmable valve, catheter-related complications, e.g. proximal (36%) or distal obstructions (30%), were the main reasons for surgical revision. Non-invasive pressure adjustment was performed in 73% of the children. Among the children with the programmable valve as their first shunt, 57 (75%) were adjusted, 12 (21%) had severe symptoms of over-drainage and would have required urgent surgical change of the valve if it had not been adjustable. A resetting of the opening pressure after MRI was found in 38% and accidental resetting occurred in 4%. Programmable valves are about twice as expensive as non-programmable valves. We estimated the increased cost of the valve and compared it with the savings from a reduction in the number of re-operations. The total cost for the programmable valve (as the primary shunt) in our study was less than that for expected re-operations due to over- or under-drainage when using non-programmable valves. The programmable valve was easy to handle; only one size was required and the adjustment made it possible to achieve an optimal intraventricular pressure with a lower total cost, reduced hospital stay as well as an increased quality of life for the children.

Alteration of the Pressure Setting of a Codman-Hakim Programmable Valve by a Television-Case Report-

A 7-year-old girl presented in semicomatose condition. She had received a ventriculoperitoneal shunt using a Codman-Hakim programmable valve. Head computed tomography demonstrated hydrocephalus and head radiography showed that the pressure setting of the shunt valve had changed to 60 mmH(2)O from 40 mmH(2)O. The pressure setting was returned to 40 mmH(2)O, and she was discharged because her clinical symptoms and hydrocephalus improved. One month later, she lost consciousness again and was transported to our hospital. Hydrocephalus and shunt valve pressure of 50 mmH(2)O were noted, and the pressure setting was returned to 40 mmH(2)O again. She was discharged without complications. We suspected that the valve pressure was caused by close contact with a television, because the patient tended to touch a television with her head during play. The valve pressure did not change after the television was placed on a high stand out of reach. We should recognize that there are many sources of weak magnetic fields that may influence a programmable valve in everyday life.