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Göran Zemack and Bertil Romner

A retrospective study was undertaken to assess the value of the Codman Hakim programmable valve in the treatment of 583 patients (421 adults and 162 children) with hydrocephalus of various causes (379), normal-pressure hydrocephalus (NPH) (174), an arachnoidal cyst (14), and pseudotumor cerebri (16). In all patients the programmable valve was implanted (the valve can be noninvasively adjusted to settings in the range of 30-200 mm H2O). In 73% of the cases this was their first shunt implantation. Ninety-two percent of the shunts drained to the peritoneal cavity and 8% to the atrium. In 42% of the cases valve pressure adjustment was required at least once (mean number of adjustments 1.2, maximum 23).

The authors present reprogramming statistics, and strategies for reprogramming are discussed. In 65% of the cases in which pressure adjustments were required, reprogrammings improved the patients' clinical status. The overall infection rate was 8.5% (56 of 660 valve implantations). Valve malfunction, blockage, or reprogramming difficulty occurred in 17 cases, and nontraumatic subdural fluid collections were demonstrated in 30 cases (13 of which were treated by valve pressure reprogramming alone). Of the patients undergoing first-time shunt placement, 21.5% eventually underwent shunt revision at least once, and a total of 318 revisions were performed during the 7-year follow-up period. At follow up, 97% of children and 90% of adults had improved.

In conclusion, catheter-related complications and shunt-related infections were the main reasons for revision and the major cause of shunt failure. Few incidents of valve malfunction were observed. The Hakim Codman programmable valve is of value in the treatment of hydrocephalus of all causes, especially in the treatment of patients with NPH, pseudotumor cerebri, arachnoidal cyst, aqueductal stenosis, traumatic hydrocephalus, and intraventricular hemorrhage.

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Göran Zemack and Bertil Romner

Object. The goal of this study was to assess the value of the Codman Hakim programmable valve to settings in the range of 30 to 200 mm H2O. This valve can be adjusted noninvasively for cerebrospinal fluid (CSF) drainage.

Methods. The authors conducted a single-center retrospective study of 583 patients (421 adults and 162 children) suffering from hydrocephalus of various causes (379 patients), normal-pressure hydrocephalus (174 patients), arachnoid cyst (14 patients), and pseudotumor cerebri (16 patients). In all cases a Codman Hakim programmable valve was implanted; in 82.8% of cases it was included during the patient's first shunt implantation.

In 42.4% of the cases valve pressure adjustment was required at least once (mean number of adjustments 1.2, maximum 23). The patients' clinical status improved after 64.6% of pressure adjustments. Accidental resetting of opening pressure, other than that caused by magnetic resonance (MR) imaging, was uncommon. Because MR imaging caused resetting in 26.8% of cases in which it was used, it was deemed mandatory to obtain an x-ray film after MR imaging. Valve malfunction, blockage, or adjustment difficulties occurred in 2% of valves implanted, and nontraumatic subdural fluid collections were demonstrated in 5.1% of patients (13 of whom were treated by valve pressure adjustment alone). Five-year shunt survival was 53.1% for first-time shunt implantations. The shunt infection rate was 8.5% of valve implantations. Catheter-related complications and shunt-related infections were the main reasons for surgical revision and the major cause of shunt failure. At follow-up review, 97% of children and 90% of adults had improved.

Conclusions. Because one cannot know in advance which case will turn out to be complicated, the authors' preference is to use the Codman Hakim programmable valve for all conditions in which CSF should be drained.

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Tor Ingebrigtsen and Bertil Romner

✓ The authors studied 24 patients with a Glasgow Coma Scale score of 14 or 15 and normal computerized tomography scans after minor head injury. The study protocol included obtaining serial measurements of S-100 protein in serum during the first 12 hours after injury and early magnetic resonance (MR) imaging. Four patients (17%) had detectable levels of S-100 protein in serum. The S-100 protein levels were highest immediately after trauma, declining hour by hour. In two patients, MR imaging revealed intracranial contusion. Levels of S-100 protein were not detectable in serum in one patient with MR-verified cerebral contusion, but the first measurements were made late, 6 hours after trauma. The highest serum level of S-100 protein (0.9 µg/L) was seen in a 73-year-old man 2 hours after injury. Magnetic resonance imaging revealed a contusion of the left cerebellar hemisphere, and the patient suffered permanent sequelae of impaired posture and dizziness.

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Bertil Romner, Bengt Ljunggren, Lennart Brandt and Hans Säveland

✓ Twenty-one patients were subjected to repeated assessment of cerebral blood flow velocities by means of transcranial Doppler sonography (TCDS) during the first 12 hours after subarachnoid hemorrhage (SAH). In 19 patients the study was performed following the first SAH, and in two after early rebleeds. Flow velocities did not indicate an early phase of arterial narrowing in any case. Following the first TCDS assessment, flows were evaluated repeatedly in the 19 survivors. Increased flow velocities suggesting arterial narrowing or vasospasm occurred only after a delay of at least 4 days. The results of this study favor the restoration of normal velocity patterns in surviving patients and do not indicate that an acute phase of vasospasm exists either immediately after or in the first 12 hours after SAH.

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Andreas Raabe and Bertil Romner

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Bertil Romner, Bengt Ljunggren, Lennart Brandt and Hans Saveland

✓ Thirty-six patients with a proven first subarachnoid hemorrhage (SAH) from a ruptured supratentorial aneurysm were subjected to repeated transcranial Doppler sonography assessments. Eighteen individuals (Group A) were operated on within 48 hours, while the other 18 (Group B) had surgery between 49 and 96 hours after SAH. The patients represented two clinically comparable groups. In the first 72 hours post-SAH, no increased flow velocities suggestive of arterial narrowing or vasospasm were recorded. There was no significant difference in preoperative flow velocities between the groups. Postoperative flow velocities were significantly lower in patients operated on within 48 hours (p < 0.001). Two patients, who had surgery on Day 4 post-SAH and who showed the highest recorded postoperative flow velocities, died from cerebral vasospasm and infarction. The results favor a referral system which enables early surgical intervention not only to prevent rebleeds but also aimed at reducing delayed ischemic dysfunction.

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Magnetic resonance imaging and aneurysm clips

Magnetic properties and image artifacts

Bertil Romner, Magnus Olsson, Bengt Ljunggren, Stig Holtås, Hans Säveland, Lennart Brandt and Bertil Persson

✓ The magnetic properties of 12 different types of aneurysm clip were investigated in order to identify which clips allow postoperative magnetic resonance (MR) imaging without risk. Clip-induced MR artifacts were also quantitatively studied using a geometrical phantom. Nonferromagnetic aneurysm clips like the Yaşargil Phynox, Sugita Elgiloy, and Vari-Angle McFadden clips do not appear to contraindicate MR studies performed with a FONAR β-3000M imager. There is no clip movement upon introduction of the phantom into the MR imager, and the image artifacts caused by the clips are so limited that patients harboring such clips may well be considered for MR imaging. This examination may reveal information not obtainable by any other radiological modality.

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Bertil Romner, Johan Bellner, Poul Kongstad and Hans Sjöholm

✓ Sixty-seven patients (45 males and 22 females) aged 2 to 70 years (mean 36 years) who had suffered closed head injury were investigated with daily transcranial Doppler (TCD) recordings. A total of 470 TCD recordings (mean 7) were made during Days 1 to 14 after admission. Blood flow velocities were determined in the middle cerebral artery (MCA) and the extracranial internal carotid artery (ICA). Twenty-seven (40%) of the 67 patients demonstrated traumatic subarachnoid hemorrhage (tSAH) on the first computerized tomography (CT) scan after the injury. Flow velocities exceeded 100 cm/second in 22 patients. Eleven (41%) of the 27 patients who showed tSAH on the first CT scan developed velocities greater than 100 cm/second, as compared to 11 (28%) of 40 patients without tSAH on CT. Two patients in whom a thick layer of tSAH was revealed on the first CT scan had MCA flow velocities exceeding 200 cm/second for several days. Measurements of cerebral blood flow (CBF) with single-photon emission CT (SPECT) were performed in six tSAH patients who showed TCD flow velocities exceeding 120 cm/second (uni- or bilaterally) to determine whether the increase in velocity reflected vasospasm or hyperemia. The SPECT studies verified ischemia in five patients but revealed general hyperemia in one. The bilateral increase in MCA flow velocities in the latter case was due to high-volume flow through the MCA secondary to elevated CBF rather than arterial narrowing. In one patient with a thick layer of subarachnoid blood on a CT scan obtained at admission, MCA flow velocities exceeded 220 cm/second bilaterally on Day 8 after the head injury. A SPECT measurement obtained on the same day reflected bilateral ischemia. In this patient flow velocities decreased, with a corresponding normalization of CBF, after 5 days of intravenous nimodipine administration. The MCA/ICA ratio correlated well with the distribution of CBF in the six patients studied using SPECT. This report suggests that vasospasm is an important secondary posttraumatic insult in patients suffering severe head injury and, in some cases, is probably treatable by administration of intravenous calcium channel blockers.

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Göran Zemack, Johan Bellner, Peter Siesjö, Lars-Göran Strömblad and Bertil Romner

Object. The goal of this study was to assess the value of making adjustments in the opening pressure of a shunt valve and to determine shunt survival in children and young adults in whom an adjustable valve was used to manage cerebrospinal fluid drainage.

Methods. The authors conducted a single-center retrospective study of 158 children and young adults who had received 199 Codman Hakim programmable valves (noninvasively adjustable to settings in the range of 30–200 mm H2O). The mean age at which the patients underwent shunt implantation was 4.4 years (median 0.4 years, maximum 18 years); 94 patients were younger than 2 years of age, including 14 patients with a gestational age younger than 38 weeks at the time of implantation. In 84 (53.2%) of the 158 patients, valve pressure adjustment was required at least once (mean 1.3 times, maximum 16 times). Among the 202 adjustments made in patients the reason for adjustment was underdrainage in 74 adjustments (36.6%) and overdrainage in 119 (58.9%). The clinical status of the patient improved after 121 (69.1%) of 175 adjustments and after 58 (73.4%) of 79 minor adjustments (less than or equal to ± 20 mm H2O). The shunt infection rate was 13 (10.9%) of 119 patients. Shunt survival was 60.5% at 1 year, 47.1% at 2 years, and 43.9% at 3 years of follow-up review.

Conclusions. Adjustment of the valve's opening pressure further improves outcome in pediatric patients.