TECHNICAL NOTE

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

AbstractIntroduction Despite the existence of wide variety of shuntsystems, physiological regulation of intracranial pressure inshunted patients remains a utopian dream. Lumboperitonealshunts (LPS) have long been used for treating idiopathicintracranial hypertension and other types of communicat-ing hydrocephalus. Although they can provide rapid andeffective symptom resolution, cerebrospinal fluid (CSF)over-drainage remains a common complication of LPS. Weintroduce the use of the Miethke DualSwitch Valve (M-DSV) for LPS and describe our preliminary experiencewith these valves in managing and avoiding CSF over-drainage. This is the first description of the use of M-DSVfor LPS.Materials and methods Over 6 months, we treated fivepatients with LPS using M-DSV. Prior to the use of the M-DSV, four patients experienced significant over-drainagesymptoms secondary to LPS. Data was collected prospec-tively, including preoperative details and clinical outcome.Results Five patients (age range, 22 to 71 years) wereoperated upon. Three patients had pseudotumor cerebri, onepatient had an LPS for treatment of a posterior fossa

pseudomeningocele, and one had an LPS for treatment ofcauda equina syndrome secondary to lumbar dural ectasia.Four patients had a history of clinical over-drainagesecondary to pre-existing LPS systems. The fifth patienthad an LPS revision after the previous LPS migrated.Follow-up ranged from 5 to11 months (mean, 7.83 months). All patients had a good outcome with immediateresolution of over-drainage symptoms and are currentlyasymptomatic.Conclusions The use of M-DSV in LPS is an effectivealternative for avoiding posture-related over-drainage andmanaging patients with LPS-related over-drainage symp-toms. Further experience is required to address the long-termoutcome, balancing sufficient drainage while preventingover-drainage.

Keywords Lumboperitoneal shunt . Over-drainage .

Miethke DualSwitch Valve . Gravity-assisted valve .

Pseudotumor cerebri . Intracranial pressure

Introduction

Physiological regulation of intracranial pressure (ICP) hasbeen an unachievable goal since the introduction of shuntsfor cerebrospinal fluid (CSF) diversion despite the develop-ment of over 200 different types of shunts with more thanthousand pressure permutations within the last 50 years [1].

Lumboperitoneal shunts (LPS) have long been used forthe treatment of idiopathic intracranial hypertension (pseu-dotumor cerebri (PTC)), postoperative pseudomeningocele,CSF leaks, and "communicating hydrocephalus". Althoughthey can provide a rapid and effective resolution ofsymptoms, there are major disadvantages associated withLPS 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, Israele-mail: dr.suhas@gmail.come-mail: sconsts@netvision.net.il

A. KeslerNeuro-ophthalmology Unit, Department of Ophthalmology,Tel Aviv University,Tel Aviv Sourasky Medical Center, 6 Weizman Street,Tel Aviv 64239, Israel

Acta Neurochir (2010) 152:17931800DOI 10.1007/s00701-010-0724-4

myriad manifestations, occasionally associated with ac-quired Chiari malformation [2].

Various methods have been used to avoid or manage CSFover-drainage with LPS, including upgrading the shunt tohigher-pressure settings, using programmable valves, andusing flow-restricting or hydrostatic devices [35].

Hydrostatic valves take into account the patientsposture, restricting CSF drainage during upright positions.The Miethke DualSwitch Valve (M-DSV) system is a typeof horizontalvertical (HV) switcher type of hydrostaticvalve 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 avoidand manage over-drainage in different types of adulthydrocephalus [1, 69].

Flow-restricting devices, as a rule, require the deviceplacement parallel to the body axis, making it cumbersometo use together with LPS. The M-DSV designed for LPScan conveniently be interposed in line with the shunttubing. This, along with many other advantages describedin this paper, makes it an attractive device for LPS.

We introduce the use of the M-DSV to avoid and manageover-drainage in LPS and describe our preliminary experiencewith these valves for LPS. This is the first case series focusingon the use of M-DSVas a restrictive component in LPS.

Materials and methods

During the period of June to December 2009, we treatedfive patients with LPS using an M-DSV. All patients hadLPS revisions with the M-DSV, four for clinically signif-icant over-drainage (presenting with new-onset positionalheadaches) and one for distal shunt migration.

Prospectively collected data included patient demo-graphics, clinical status (including details of prior surgeriesand preoperative neurological and neuro-ophthalmologicalstatus), operative findings, and clinical and neuro-ophthalmological follow-up.

The M-DSV technology

The M-DSV valve consists of two integrated chambers,each with a different opening pressure (www.miethke.com).The low-pressure chamber is activated when the patient isrecumbent. The high-pressure chamber is activated whenthe patient is in an upright position. Toggling betweenchambers is by a heavy tantalum sphere which occludes thedrainage through the low-pressure chamber as soon as thepatient is in upright position (Fig. 1). Switching betweenpressure settings is not gradual but occurs at an angle ofabout 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) to60-70, and 40 cm H2O when at an angle between 60-70to 90 (upright). Thus, the ICP is kept in a physiologicalrange whether the patient is supine or upright (C. Miethke,personal communication, 2009). The M-DSV has beenevaluated in adult hydrocephalus and has been found tomaintain ICP within physiological limits independent ofpatient 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, and50 cm H2O for the upright position. When supine, the M-DSV operates like a conventional differential pressurevalve. The recommended standard pressure setting for thelower-pressure valve, according to the manufacturer (C.Miethke GmbH & Co. KG) is 10 cm H2O (5 cm H2O forpatients with normal-pressure hydrocephalus (NPH)). Thehigh-pressure side of the valve is calculated as a function ofthe sitting height and is chosen in such a way that with thepatient upright, a ventricular pressure of at least 5 cm H2Owill be maintained under all circumstances (C. MiethkeGmbH & Co. KG).

Suitable pressure is calculated as follows:

1 Measure the distance between the third ventricle (at thelevel of the foramen of Monro, as roughly measured fromthe 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. Ventricularpressure in the patient will then be kept between 5 cmH2O and +5 cm H2O at all times.

Surgical aspects of the M-DSV

The M-DSV valve is interposed and placed in theabdominal wall (or at the flank) (manufacturer's recom-

Fig. 1 Schematic representation of the valve technology. 1Inletconnecting to the intrathecal catheter. 2 Outlet towards the peritonealcatheter. 3 Low-pressure chamber. 4 High-pressure chamber. 5 Ballresponsible ("switch") for toggling between pressure chambersdepending on the position

1794 Acta Neurochir (2010) 152:17931800

mendation: arcus costalis). The valve function requires it beplaced in an axis parallel to the body (direction as indicatedby an arrow on the valve). The specific design of the M-DSV meant for the LPS has a perpendicular connectorallowing it to be interposed in line with the LPS [Fig. 2].An antechamber that can be used for pressure measurementand fluid aspiration is located proximal to the valve. Theantechamber has a narrow connecter for connection withthe intrathecal catheter. The valve is connected distally toan abdominal catheter for intra-peritoneal insertion; alter-natively, it can be connected to a pre-existing distalabdominal catheter using a straight connector. The valvemay be anchored to the tissue layers using sutures tomaintain its orientation with respect to the axis of the body.

We used a valve with opening pressures of 10/40 for allfive patients in accordance with their sitting height. Thepatients were regularly followed, and the outcomes wereevaluated based on the preoperative and postoperativesymptomatology.

Results

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

LPS and for using the M-DSV, and follow-up aresummarized in Table 1.

Initial indications for LPS

Three patients had PTC, one patient had an LPS fortreatment of a posterior fossa pseudomeningocele (follow-ing an excision of a tentorial meningioma), and one elderlypatient had an LPS for treatment of cauda equina syndromesecondary to a lumbar dural ectasia associated withankylosing spondylitis.

Indications for LPS revision

Four patients (all females) had a history of posturalheadaches consistent with over-drainage, secondary topre-existing LPS systems. One of the patients had a historyof upgrading her valve (medium pressure to Delta 2); twopatients had a prior LPS, one with a medium-pressure valve(PS medical, Medtronic) and another with a Delta 1.5valve. The fourth patient, with a valveless LPS for PTC,presented with visual deterioration associated with posturalheadaches that were attributed to over-drainage secondaryto LPS and not raised ICP. The fifth patient, an elderlymale, had an LPS revision with an M-DSV after theprevious LPS (placed for treatment of a symptomaticlumbar dural ectasia) migrated.

Operative and perioperative course

Four valves were placed along the right side and onealong the left. There were no technical difficulties in anyof the patients, including in the three PTC patients whowere severely obese. Patients were discharged within 2-3 days following surgery. There were no exacerbations ofpreoperative symptoms following surgery. One patientrequired a distal revision 2 weeks later for proximalmigration of the peritoneal catheter to the new valvepocket.

Long-term follow-up

Average follow-up was 7.83 months, ranging from 5 to11 months. All four patients presenting with over-drainage symptoms had immediate significant improve-ment and are currently asymptomatic. There were noexacerbations in any of the PTC patients. The patient whopresented with visual deterioration experienced improve-ment. The patient with the cauda equina syndromesecondary to a lumbar dural ectasia has had completerelief of his symptoms with no symptoms of over-drainage. None of the patients had any ophthalmologicalsequelae.

Fig. 2 Photograph of the valve constituents. The arrows show theinlet (1) to the valve and outlet (2) from the valve. The inlet has anarrow connecter for the intrathecal catheter and leads to anantechamber. The outlet has a connector for the abdominal catheterfor intra-peritoneal insertion. An arrow on the valve indicates thedirection of the valve, to be placed parallel to the body axis. Noticethat the M-DSV meant for LPS has been specifically designed withperpendicular connectors to allow it to be easily interposed in linewith the LPS. The valve may be anchored to the tissue layers usingsutures to maintain its orientation with respect to the axis of the body

Acta Neurochir (2010) 152:17931800 1795

Illustrative case

A 22-year-old obese female presented with severe andconstant headaches. Her neurological examination wasnormal apart from bilateral papilledema. Imaging wasunremarkable, and she was diagnosed with PTC. She faileda trial of conservative measures including weight loss andmedical therapy with Diamox (acetazolamide) as shedeveloped side effects. Subsequently, an LPS with amedium-pressure valve (PS Medical, Medtronic) wasinserted. Although she initially experienced marked im-provement in her headaches, she later began complaining ofpositional headaches which improved on recumbent posi-tion. She had no significant relief of symptoms withconservative measures over a period of 1 year. One of theepisodes was severe enough to bring her to the emergencydepartment. An urgent head CT and shunt radiographscompleted during this episode were normal. Puncture of theshunt chamber revealed free flow but a very low pressure of2 cm H2O.

Two months later, with a provisional diagnosis of low-pressure headaches, she underwent a valve upgrade to aDelta 2 (PS Medical, Medtronic). The headaches initiallyimproved but the effect wore off, and she continued tosuffer substantial headaches, especially when in the uprightposition. The headaches worsened with physical activityand led to severe impairment of quality of life. Eightmonths later, she underwent a valve revision with an M-DSV 10/40. The patient improved immediately aftersurgery and no longer complained of postural headaches.At 11-month follow-up, she continues to remain symptomfree with a normal fundus.

Discussion

Several authors have reported a clear reduction in theincidence of over-drainage among patients with adulthydrocephalus treated by ventriculoperitoneal shunts(VPS) with M-DSV [1, 610]. In view of these previouslypublished results showing the advantage of M-DSV in VPSfor various hydrocephalic pathologies in adults, we opted toutilize the M-DSV in our patients with LPS. Our series is thefirst series focusing on the usage of M-DSV for LPS in anattempt to avoid and manage posture-related over-drainage.

Since the introduction of LPS in the 1950s and silasticcatheters in 1975 by Selman et al. [11], LPS have evolvedas an important option for CSF diversion, serving as analternative to VPS for several indications [11, 12]. LPShave been used to treat a host of conditions including CSFrhinorrhea, normal pressure hydrocephalus, lumbar pseu-domeningocele, slit ventricle syndrome, and in particularPTC [13, 14].Ta

ble1

Patient

details

Serialno:Patient

characteristics

Indicatio

nforLPS

Valve

used

priorto

M-D

SV

Clin

ical

Features

Indicatio

nforLPS

revision

OutcomeafterLPSwith

M-D

SV

122/F

PTC

Medium

pressure

(PSmedical),

over-drainageY

(Delta

2.0)

Posturalheadaches

Clin

ical

over-drainage

Improved

inclinical

symptom

swith

norm

alvision,andfundus

262/F

Postoperativ

epseudomeningocele

aftersurgeryfortentorial

meningiom

a

Cystoperitoneal

shuntY

VPS

(Medium-pressurevalve),

malfunctio

nY

LPSwith

medium-pressurevalve

Posturalheadaches

Clin

ical

over-drainage

Improved

symptom

s,no

pseudomeningocele

371/M

Ankylosingspondylitiswith

symptom

atic

duralectasia

LPSthat

migrated.

Nonfunctio

nalUrinary

incontinence

and

pseudomeningocele

ofthe

lumbararea

LPSmalfunctio

nIm

proved

symptom

s

428/F

PTCwith

optic

nervefenestratio

nDelta

1.5

Posturalheadaches

Clin

ical

over-drainage

Improved

symptom

s

530/F

PTC

Valveless

Posturalheadaches,Visual

deterioration,

ICPshow

ednegativ

evalue;

Fundus-optic

atrophy

Clin

ical

over-drainage

Improved

symptom

s

Y:representschange

to,follo

wingsymptom

sof

overdrainage.

1796 Acta Neurochir (2010) 152:17931800

LPS offer numerous advantages over VPS includingavoidance of the need to access ventricular cavities withinthe brain parenchyma, thereby avoiding potential compli-cations such as cortical venous injury or hemorrhage, aswell as lower seizure and infection rates [15, 16] and a verylow mortality rate compared to VPS [5, 17]. In the contextof communicating hydrocephalus, LPS are probably morephysiological, maintaining patency of all ventricular cavi-ties compared to a VPS [18], as they access CSF from boththe ventricles and cortical subarachnoid spaces through thespinal subarachnoid space.

Although LPS provide rapid and effective resolution ofthe primary symptoms, several disadvantages are associatedwith their use. Complication rates associated with thecurrent LPS systems are considered high [17]. Orthostaticover-drainage and its myriad manifestations are especially aconcern when using LPS [14]. The incidence of symptom-atic over-drainage secondary to LPS is reported to be ashigh as 15-20% [1921].

Although over-drainage is a general concern whenplacing an LPS, patients who receive LPS with valves hada lower frequency of over-drainage symptoms compared topatients whose shunts had no valve [22].

Historically, lumboperitoneal shunting was performed byimplanting a single tube with the proximal end in thelumbar CSF space and the distal end intraperitoneally.Tonsillar herniation was a common sequel following theseshunts [2]. Spetzler et al. and others introduced LPS with avalve system [11, 23]. Valve types used for LPS can besubdivided into three types:

1 conventional differential pressure valves with a fixedopening pressure,

2 adjustable devices, enabling noninvasive percutaneouschange of the opening pressure, and

3 hydrostatic valves that take into account the patientposture and include flow-restricting devices that changetheir flow regulation in a gradual way (analog type ofvalves e.g., Miethke's ShuntAssistant) or have an abruptchange of regulation status (e.g., as with the M-DSV).

Many of these valves are not subject to reliable qualitycontrol [24]. In their detailed evaluation of shunt valves,Czosnyka et al. concluded that the actual in vivo behaviorof the majority of valves currently available may notexactly match the manufacturers product information.Significant problems encountered by Czosnyka and col-leagues included over-drainage, sensitivity of CSF flow tobody posture, blockage caused by subcutaneous pressure,and changes in settings related to external magnetic fields[2527]. Czosnyka et al. reported that the over-drainagerate might be reduced in Medtronic PS Medical LPSbecause of the very high hydrodynamic resistance of thethin tube (internal diameter of 0.8 mm, compared with

1.2 mm for most distal drains). On the other hand, suchhigh resistance may potentially cause the shunt to under-drain in horizontal body positions [27].

Various additional methods have been used to avoid andmanage CSF over-drainage, including upgrading the valveto a higher-pressure valve, adding an anti-siphon device,and using a programmable valve, all with inconsistentresults [35, 28, 29]. Upgrading the valve pressure settingto overcome over-drainage may lead to increased resis-tance, especially in the supine position, and may lead tosymptoms of under-drainage.

Wang et al. reported that among the74 patients with LPS,11 had symptoms of over-drainage. Seven of these patientshad a valveless system, and four had a HV valve. In nine ofthese 11 patients, symptoms resolved after a valve wasinserted or after their valves were set to a higher pressure[5]. The Integra HV valve (Integra LifeSciences, Plains-boro, NJ) utilized in that series was introduced in the 1990sfor LPS. The Integra HV incorporated two different valvesto allow for control of CSF flow when a patient is in eitherupright or supine position. In addition, an antechamber isavailable for access to the LPS.

Chang et al. in their series of LPS with Codman Hakimprogrammable valves for NPH observed over-drainagesymptoms in five of 32 patients, but they recovered afterincreasing the valve pressure. According to Chang et al.,the major advantage in the use of programmable valve isthe ability to modify the pressure and thus manage over-drainage or under-drainage noninvasively. Thus, inclusionof the Codman Hakim programmable valve in the LPS mayavoid the need for a second operation in which a differentpressure valve is implanted [3].

Nadkarni et al. placed a ventricular access device (VAD)and an LPS using a Codman Hakim programmable shuntwith a SIPHONGUARD (Codman Corp.). The VAD wasmeant for ICP measurement, and the shunt also had a flow-limiting device, the (flow-restricting device [30]). Thisadd-on device increases resistance linearly with high CSFflow and may therefore prevent over-drainage [4]. Asignificant disadvantage of programmable valves is findingthe correct pressure as the rate of CSF production and thepressureflow curve are not precisely known in individualpatients. Also, the programming may be inaccurate espe-cially if the patient is obese, as is often the case for patientswith PTC. Additionally, since the main problem forpressure valves is maintaining sufficient CSF drainagewhile the patient is in supine, sitting, and standingpositions, they may reduce but cannot exclude over-drainage [31]. In addition, valve pressure setting may bealtered even by low magnetic fields [32]. The additionalplacement of a VAD requires an additional procedure(usually stereotaxy-based) and entails the potential morbid-ity of an invasive cortical procedure and infection. Zemack

Acta Neurochir (2010) 152:17931800 1797

and Romner conducted a cost analysis of programmablevalves and concluded that the increased cost cannot beadequately justified with the current evidence of complica-tions associated with these valves [32].

In principle, siphoning per se should not significantlyaffect an LPS due to the comparable heights of theproximal and distal tips of the shunt system. However,the pressure at the proximal end of the valve reflects thehydrostatic pressure of a fluid-filled column (between theintracranial compartment and the spinal subarachnoidspace upstream from the tip of the intrathecal catheter).As the valve is a pressure-regulated system, the elevatedpressure differential across the valve during uprightpositions increases the flow and CSF drainage rates ascompared to that during a supine position, hence the highrate of over-drainage in LPS.

The efficacy of an anti-siphon device to counter over-drainage in LPS is questionable [30]. The reason is, asdiscussed above, that true siphoning may not have a role inthe CSF dynamics of an LPS. Also, susceptibility tosubcutaneous pressures in general and during routineactivity in particular raises questions over their efficacy.Hence, valves with anti-siphon devices (such as the Deltavalves) probably have a limited role to play in preventingLPS over-drainage.

The concept of gravitational shunts has existed since1970s and has been found to have encouraging results inavoiding posture-related over-drainage in adult and child-hood hydrocephalus [3335]. In 1975, Hakim presented theHakim Lumbar HV valvethe first technically maturegravitational shunt. The first concept of the switcher typeof gravitational valve was introduced with MarionsSophysa AS valve in 1983. This valve too was not wellaccepted. The first valve regulation for HV change wasintroduced by Hakim-Cordis in the 1980s. These valves didnot stand the test of time and are mostly no longer available[31].

The M-DSV system is also a type of kind of a HVswitcher type of valve. As described above in thesubsection The M-DSV Technology under section Materialsand Methods, the valve resistance changes depending onthe patient position, toggling between a low-resistanceopening pressure while in supine position and a high-resistance opening pressure while in upright position.

Several authors found clear reduction in over-drainageamong patients with adult hydrocephalus who were treatedby VPS with M-DSV [1, 610]. Mier et al. in their series ofM-DSV for 128 patients with NPH treated by VPS with M-DSV found an over-drainage rate of 2% [6]. Another studyby the same author compared different valves, reporting anover-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 threepatients with over-drainage. Six patients, in this series,experienced under-drainage (importantly all bedriddenpatients) [9].

In our series, four patients with prior LPS (variousvalves including two with Delta valves) presented withsymptoms of over-drainage. In view of the prior publishedresults showing the advantage of M-DSV in VPS forvarious hydrocephalic pathologies in adults, we opted toplace the M-DSV in these LPS patients with apparentsuccess. In the fifth patient, by using an M-DSV, we seemto have averted the possible complication of over-drainagewhich elderly patients are prone to [37].

Although in our small series we seem to have overcomethe issue of over-drainage in all patients using the samelower-pressure setting (10 cm H2O), over-drainage may stilloccur in some patients. In such cases, an M-DSV with ahigher low-pressure setting could be used. Unlike mostprogrammable valves, opening pressures of the M-DSVvalves are not affected by magnetic field, and the titaniumcasing makes it resistant to changes in subcutaneouspressure [38, 39]. The M-DSV also has an antechamberthat can be used for pressure measurement, fluid aspirationfor analysis, and ruling out proximal malfunction. Also,unlike other flow-restricting devices (where the requirementfor the device to be placed parallel to the body axis foreffective action may be inconvenient in cases of LPS), theM-DSV designed for LPS can conveniently be interposedin line with the shunt tubing.

Unlike the Cordis HV valve and the Chabbra valve, theforce exerted by CSF flow in the M-DSV is downward onthe gravity-propelled ball whenever the patient is in theupright position, supporting the closing mechanism of thetantalum ball, as opposed to the other two valves wherethe CSF flows against the gravity-activated closingmechanism of the balls. Therefore, in the M-DSV, theforces acting upon the tantalum ball closing the low-pressure chamber become stronger with rising ICP and/orhydrostatic pressure. Thus, the danger that the closingmechanism will be influenced by normal activities ofdaily life such as walking, running, or other valsalvamaneuvers is much lower with the M-DSV than with theother valves. Simulation of such normal daily activities invivo proved the superiority of the closing mechanism of thetantalum ball in the M-DSV over those in the Cordis HVvalve and the Chabbra valve [39]. Conventional radiographsallow checking of the graduation and position of the M-DSV and can also test the tantalum ball movements [39].

While hydrostatic valves theoretically have a higher riskof clogging [40, 41], the M-DSV seems to have a lower riskof clogging due to a larger diaphragm surface area, andhence may maintain CSF flow irrespective of its composi-tion [35, 39].

1798 Acta Neurochir (2010) 152:17931800

One possible disadvantage of the M-DSV valves is thefixed pressure settings. Any change of settings requires anoperative intervention. Although our patients had goodoutcomes, shunt revisions to implement necessary pressurechanges are a definite possibility. Tsunado et al. in theirstudy on treatment of adult hydrocephalus with M-DSVhad a rate of 7.5% shunt revisions due to under-drainage[9].

The M-DSV has been proven to establish a physiologicalCSF diversion irrespective of patient posture and CSFcomposition in adult hydrocephalus [79, 39]. Our attemptto exhibit the same for LPS seems to hold promise. Therestill remains the need for larger studies as well as longerfollow-up.

Conclusions

Using the M-DSV in LPS may balance the need foreffective CSF drainage on one hand while preventingover-drainage on the other. However, controlled studiesare indispensable, and further evaluation of this valve,both as a primary choice for LPS and in revisions forover-drainage, should be sought. Our early experiencehighlights the advantages of this valve for patients withLPS.

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

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c.701_2010_Article_724.pdfMiethke DualSwitch Valve in lumboperitoneal shuntsAbstractAbstractAbstractAbstractAbstractIntroductionMaterials and methodsThe M-DSV technologySurgical aspects of the M-DSV

ResultsInitial indications for LPSIndications for LPS revisionOperative and perioperative courseLong-term follow-up

Illustrative caseDiscussionConclusionsReferences