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Podgoršak A, Flürenbrock F, Trimmel NE, Korn L, Oertel MF, Stieglitz L, Fernandes Dias S, Hierweger MM, Zeilinger M, Weisskopf M, Schmid Daners M. Toward the "Perfect" Shunt: Historical Vignette, Current Efforts, and Future Directions. Adv Tech Stand Neurosurg 2024; 50:1-30. [PMID: 38592526 DOI: 10.1007/978-3-031-53578-9_1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
As a concept, drainage of excess fluid volume in the cranium has been around for more than 1000 years. Starting with the original decompression-trepanation of Abulcasis to modern programmable shunt systems, to other nonshunt-based treatments such as endoscopic third ventriculostomy and choroid plexus cauterization, we have come far as a field. However, there are still fundamental limitations that shunts have yet to overcome: namely posture-induced over- and underdrainage, the continual need for valve opening pressure especially in pediatric cases, and the failure to reinstall physiologic intracranial pressure dynamics. However, there are groups worldwide, in the clinic, in industry, and in academia, that are trying to ameliorate the current state of the technology within hydrocephalus treatment. This chapter aims to provide a historical overview of hydrocephalus, current challenges in shunt design, what members of the community have done and continue to do to address these challenges, and finally, a definition of the "perfect" shunt is provided and how the authors are working toward it.
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Affiliation(s)
- Anthony Podgoršak
- Product Development Group Zurich, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Fabian Flürenbrock
- Institute for Dynamic Systems and Control, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Nina Eva Trimmel
- Center for Preclinical Development, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Leonie Korn
- Institute for Dynamic Systems and Control, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Markus Florian Oertel
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Lennart Stieglitz
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sandra Fernandes Dias
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Melanie Michaela Hierweger
- Center for Preclinical Development, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Melanie Zeilinger
- Institute for Dynamic Systems and Control, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland
| | - Miriam Weisskopf
- Center for Preclinical Development, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Marianne Schmid Daners
- Institute for Dynamic Systems and Control, Department of Mechanical and Process Engineering, ETH Zurich, Zurich, Switzerland.
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A mechatronic test-bench to investigate the impact of ventricular pulsation in hydrocephalus. Biomed Signal Process Control 2022. [DOI: 10.1016/j.bspc.2022.103579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Combination of ultrasound and rtPA enhances fibrinolysis in an In Vitro clot system. PLoS One 2017; 12:e0188131. [PMID: 29145482 PMCID: PMC5690612 DOI: 10.1371/journal.pone.0188131] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 11/01/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Catheter-based lysis with recombinant tissue plasminogen activator (rtPA) is a well-established therapy for spontaneous intracerebral hemorrhage (ICH). The effectiveness of this therapy can be increased with ultrasound, but the optimal conditions are not yet clearly established. Using a novel in vitro system of blood clots previously developed by our group, we investigated various parameters of intralesional sonothrombolysis using an endosonography catheter in combination with rtPA. METHODS Standardized human blood clots were equipped with a drainage catheter and weighed before and after 4 treatments: control (drainage only), rtPA only, ultrasound only and the combination of rtPA+ultrasound. The effectiveness of ultrasound was further analysed in terms of optimal frequency, duration and distance to the probe. Temperature and acoustic peak rarefaction pressure (APRP) were assessed to analyse potential adverse effects and quantify lysis. Histo-morphological analysis of the treated clots was performed by H&E staining and confocal laser scanning microscopy using fluorescent fibrinogen. RESULTS The combined treatment rtPA+ultrasound achieved the highest lysis rates with a relative weight of 30.3%±5.5% (p≤0.0001) compared to all other groups. Similar results were observed when treating aged clots. Confocal fluorescent microscopy of the treated clots revealed a rarefied fibrin mesh without cavitations. No relevant temperature increase occurred (0.53±0.75°C). The optimal insonation treatment time was 1 hour. APRP measurements showed a lysis threshold of 515.5±113.4 kPa. Application of 10 MHz achieved optimal lysis and lysis radius, while simultaneously proving to be the best frequency for morphologic imaging of the clot and surrounding tissue. CONCLUSIONS These promising data provide the basis for an individualized minimal invasive ICH therapy by rtPA and sonothrombolysis independent of ICH age.
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Goffin C, Leonhardt S, Radermacher K. The Role of a Dynamic Craniospinal Compliance in NPH—A Review and Future Challenges. IEEE Rev Biomed Eng 2017; 10:310-322. [DOI: 10.1109/rbme.2016.2620493] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Lutz BR, Venkataraman P, Browd SR. New and improved ways to treat hydrocephalus: Pursuit of a smart shunt. Surg Neurol Int 2013; 4:S38-50. [PMID: 23653889 PMCID: PMC3642745 DOI: 10.4103/2152-7806.109197] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2012] [Accepted: 11/08/2012] [Indexed: 11/14/2022] Open
Abstract
The most common treatment for hydrocephalus is placement of a cerebrospinal fluid shunt to supplement or replace lost drainage capacity. Shunts are life-saving devices but are notorious for high failure rates, difficulty of diagnosing failure, and limited control options. Shunt designs have changed little since their introduction in 1950s, and the few changes introduced have had little to no impact on these long-standing problems. For decades, the community has envisioned a “smart shunt” that could provide advanced control, diagnostics, and communication based on implanted sensors, feedback control, and telemetry. The most emphasized contribution of smart shunts is the potential for advanced control algorithms, such as weaning from shunt dependency and personalized control. With sensor-based control comes the opportunity to provide data to the physician on patient condition and shunt function, perhaps even by a smart phone. An often ignored but highly valuable contribution would be designs that correct the high failure rates of existing shunts. Despite the long history and increasing development activity in the past decade, patients are yet to see a commercialized smart shunt. Most smart shunt development focuses on concepts or on isolated technical features, but successful smart shunt designs will be a balance between technical feasibility, economic viability, and acceptable regulatory risk. Here, we present the status of this effort and a framework for understanding the challenges and opportunities that will guide introduction of smart shunts into patient care.
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Affiliation(s)
- Barry R Lutz
- Department of Bioengineering, University of Washington, Seattle, WA, USA
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Kandadai MA, Raymond JL, Shaw GJ. Comparison of electrical conductivities of various brain phantom gels: Developing a 'Brain Gel Model'. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2012; 32:2664-2667. [PMID: 23139442 PMCID: PMC3489480 DOI: 10.1016/j.msec.2012.07.024] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The use of conducting gels to mimic brain and other tissues is of increasing interest in the development of new medical devices. Currently, there are few such models that can be utilized at physiologic temperatures. In this work, the conductivities of agar, agarose and gelatin gels were manipulated by varying NaCl concentration from 0-1 mg/ml. The AC conductivity was measured at room and physiological temperatures (37°C) in the 100-500 Hz frequency range. Conductivity (σ) was nearly independent of frequency but increased linearly with NaCl concentration and was higher at physiological temperatures in these gels. A formula for predicting conductivity as a function of NaCl concentration was derived for each gel type. The overall goal is to develop a 'brain gel model', for studying low frequency electrical properties of the brain and other tissues at physiological temperatures.
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Affiliation(s)
- Madhuvanthi A. Kandadai
- Department of Emergency Medicine, College of Medicine, 231 Albert Sabin Way, University of Cincinnati, Cincinnati, Ohio 45267-0769
| | - Jason L. Raymond
- Department of Biomedical Engineering, 2901 Campus Drive, ML 0048, University of Cincinnati, Cincinnati, Ohio 45221-0048
| | - George J. Shaw
- Department of Emergency Medicine, College of Medicine, 231 Albert Sabin Way, University of Cincinnati, Cincinnati, Ohio 45267-0769
- Neuroscience Graduate Program, CARE/Crawley Building Suite E-870, Cincinnati, OH 45267
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Basati S, Desai B, Alaraj A, Charbel F, Linninger A. Cerebrospinal fluid volume measurements in hydrocephalic rats. J Neurosurg Pediatr 2012; 10:347-54. [PMID: 22880890 DOI: 10.3171/2012.6.peds11457] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object Experimental data about the evolution of intracranial volume and pressure in cases of hydrocephalus are limited due to the lack of available monitoring techniques. In this study, the authors validate intracranial CSF volume measurements within the lateral ventricle, while simultaneously using impedance sensors and pressure transducers in hydrocephalic animals. Methods A volume sensor was fabricated and connected to a catheter that was used as a shunt to withdraw CSF. In vitro bench-top calibration experiments were created to provide data for the animal experiments and to validate the sensors. To validate the measurement technique in a physiological system, hydrocephalus was induced in weanling rats by kaolin injection into the cisterna magna. At 28 days after induction, the sensor was implanted into the lateral ventricles. After sealing the skull using dental cement, an acute CSF drainage/infusion protocol consisting of 4 sequential phases was performed with a pump. Implant location was confirmed via radiography using intraventricular iohexol contrast administration. Results Controlled CSF shunting in vivo with hydrocephalic rats resulted in precise and accurate sensor measurements (r = 0.98). Shunting resulted in a 17.3% maximum measurement error between measured volume and actual volume as assessed by a Bland-Altman plot. A secondary outcome confirmed that both ventricular volume and intracranial pressure decreased during CSF shunting and increased during infusion. Ventricular enlargement consistent with successful hydrocephalus induction was confirmed using imaging, as well as postmortem. These results indicate that volume monitoring is feasible for clinical cases of hydrocephalus. Conclusions This work marks a departure from traditional shunting systems currently used to treat hydrocephalus. The overall clinical application is to provide alternative monitoring and treatment options for patients. Future work includes development and testing of a chronic (long-term) volume monitoring system.
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Affiliation(s)
- Sukhraaj Basati
- Department of Bioengineering, University of Illinois at Chicago, Illinois 60607-7052, USA
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Basati SS, Harris TJ, Linninger AA. Dynamic brain phantom for intracranial volume measurements. IEEE Trans Biomed Eng 2010; 58:1450-5. [PMID: 20501343 DOI: 10.1109/tbme.2010.2050065] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Knowledge of intracranial ventricular volume is important for the treatment of hydrocephalus, a disease in which cerebrospinal fluid (CSF) accumulates in the brain. Current monitoring options involve MRI or pressure monitors (InSite, Medtronic). However, there are no existing methods for continuous cerebral ventricle volume measurements. In order to test a novel impedance sensor for direct ventricular volume measurements, we present a model that emulates the expansion of the lateral ventricles seen in hydrocephalus. To quantify the ventricular volume, sensor prototypes were fabricated and tested with this experimental model. Fluid was injected and withdrawn cyclically in a controlled manner and volume measurements were tracked over 8 h. Pressure measurements were also comparable to conditions seen clinically. The results from the bench-top model served to calibrate the sensor for preliminary animal experiments. A hydrocephalic rat model was used to validate a scaled-down, microfabricated prototype sensor. CSF was removed from the enlarged ventricles and a dynamic volume decrease was properly recorded. This method of testing new designs on brain phantoms prior to animal experimentation accelerates medical device design by determining sensor specifications and optimization in a rational process.
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Affiliation(s)
- Sukhraaj S Basati
- Laboratory for Product and Process Design, Department of Bioengineering, University of Illinois at Chicago, Chicago, IL 60607, USA
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