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Around 10% to 30% of shunt revisions may be attributed to posture related overdrainage. Of the various siphon preventing devices available at present, two construction types are the most prominent: those using a gravitational mechanism and those using a subcutaneous membrane. Gravitational devices such as Elekta-Cordis Horizontal-Vertical Valve, Chhabra Valve, Fuji Valve, or Miethke Dual-Switch Valve are widely used.1 Their main drawback is susceptibility to malfunction when the shunt becomes displaced from its vertical axis after implantation and unpredictable operation during persistent bodily movements. The membrane devices: the Anti-Siphon Device (ASD, Heyer Schulte) or Siphon Control Device (SCD, Medtronik PS Medical) have generally proved clinically effective,2 3although in some cases these devices may obstruct the CSF drainage when the subcutaneous pressure increases or the scar tissue isolates the device from atmospheric pressure. The flow regulating Orbis-Sigma Valve (Elekta-Cordis) may also reduce clinical complications related to overdrainage in the upright body position.4 It prevents excessive CSF drainage by instantaneously increasing its hydrodynamic resistance when the drainage rate rises.
The new Codman SiphonGuard device is intended to reduce the drainage rate when the flow dramatically increases during transition from a horizontal to vertical body position. It consists of two passages for the CSF drainage. In the central, wide channel a ball on spring valve is inserted. The valve, unlike in all hydrocephalus shunts, is normally open and closes when the flow rate exceeds the specific threshold level. Then the drainage of CSF is diverted to a much thinner channel, which constitutes a high hydrodynamic resistance. This action may help to prevent posture related overdrainage.
We tested a sample of three SiphonGuards (kindly provided by Johnson and Johnson) in the United Kingdom Shunt Evaluation Laboratory5 to characterise the hydrodynamic performance of the device and its ability to reduce posture related overdrainage.
The pressure flow performance curve consisted of two straight lines of different slopes, both crossing the origin. They represent the two possible states of the SiphonGuard—low resistance ( mean of 1.5 mm Hg/ml/min) and high resistance (mean of 42 mm Hg/ml/min, figure A). The differential pressures resulting from the above values, providing the CSF flow is on average 0.3 ml/min in the horizontal body position, would be 0.45 mm Hg and 12.6 mm Hg respectively.
(A) Pressure-flow performance curves for the SiphonGuard for the low and high resistance states. (B) Switching between low and high resistance states was monitored by repetition of triangularly increasing and decreasing perfusion rate (lower plot in μl/min) controlled by computer controlled infusion pump. Switching point may be demonstrated by an abrupt increase in the pressure measured across the device (upper plot). The same device changed the resistance state at variable flow rate from 0.7 to 1.5 μl/min.
Switching between low and high resistance was initiated by a flow rate, the threshold of which varied between 0.7 and 1.8 ml/min (figure B).
Switching from the high to low resistance was initiated by the differential pressure decreasing below the threshold from 4 to 6 mm Hg.
Overall, the mechanism of the SiphonGuard seemed to work according to the designers’ intention. It is supported by the concept that, during rapid transition from horizontal to vertical body position, initial flow rate increases above 2–3 ml/min. This is enough to switch the valve to the high resistance state, limiting overdrainage. However, in practice, it may not always be the case. In patients with small or slit ventricles previously having overdrainage, CSF may not be available to produce the flow at such a high rate. Moreover, because reliable switching occurs above 1.8 ml/min, in shorter persons or in patients resting persistently in a semisitting position (for example, elderly patients watching TV or reading books) the drainage rate of 1 ml-1.5 ml may cause clinical deterioration without initiating the antisiphon action of the SiphonGuard. Another possible drawback concerns the reverse change—that is, switching back from high to low resistance, to be expected when a patient moves from a vertical to a horizontal position. The device may not return to its state of low resistance. If the resistance switching mechanism is indeed triggered by a differential pressure (with a threshold of around 5 mm Hg) the SiphonGuard may stay in the high resistance state permanently. Its high hydrodynamic resistance may force the differential pressure to persist higher than 9–16 mm Hg, under conditions when the CSF drainage rate should equal its formation rate (0.2–0.4 ml/min). Hence, it is possible that the device may remain “locked” in the high resistance state, causing underdrainage in the horizontal body position.
In vivo, the device may contribute to the significant fluctuations of pressure resulting from the difference between the operating pressures for low and high resistance—similar to that described for the Orbis-Sigma Valve. Moreover, it may not prevent the overdrainage related to nocturnal vasomotor pressure waves,5 as often reported in paediatric cases.
These reservations, based on our short laboratory study, should be taken into consideration both by neurosurgeons and the manufacturer. Whether they cause system malfunction under specific clinical conditions remains to be shown. We advocate a well controlled multicentre study on this new and interesting device together with in vivo measurements of shunt function using a CSF infusion test during tilting.6