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Zofia Czosnyka, John D. Pickard, and Marek Czosnyka


Independent testing of hydrocephalus shunts provides information about the quality of CSF drainage after shunt implantation. Moreover, hydrodynamic parameters of a valve assessed in the laboratory create a comparative pattern for testing of shunt performance in vivo. This study sought to assess the hydrodynamic parameters of the Certas valve, a new model of a hydrocephalus shunt.


The Certas valve is an adjustable ball-on-spring hydrocephalus valve. It can be adjusted magnetically in vivo in 7 steps, equally distributed within the therapeutic limit for hydrocephalus, and the eighth step at high pressures intended to block CSF drainage. The magnetically adjustable rotor is designed to prevent accidental readjustment of the valve in a magnetic field, including clinical MRI.


The pressure-flow performance curves, as well as the operating, opening, and closing pressures, were stable, fell within the specified limits, and changed according to the adjusted performance levels. The valve at settings 1–7 demonstrated low hydrodynamic resistance of 1.4 mm Hg/ml/min, increasing to 5.1 mm Hg/ml/min after connection of a distal drain provided by the manufacturer. At performance Level 8 the hydrodynamic resistance was greater than 20 mm Hg/ml/min. External programming of the valve proved to be easy and reliable. The valve is safe in 3-T MRI and the performance level of the valve is unlikely to be changed. However, with the valve implanted, distortion of the image is substantial. Integration of the valve with the SiphonGuard limits the drainage rate.


In the laboratory the Certas valve appears to be a reliable differential-pressure adjustable valve. Laboratory evaluation should be supplemented by results of a clinical audit in the future.

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Peter D. Lees and John D. Pickard

✓ The intrasellar pressure has been studied in a consecutive series of 24 patients undergoing transsphenoidal surgery for pituitary adenoma. The mean intrasellar pressure for the group was 23 ± 2.5 mm Hg (± standard error of the mean), with a mean pulse pressure of 3.5 ± 1 mm Hg. The waveform partly resembled the arterial configuration. The results are correlated with the radiological and endocrinological features of the tumors. A hypothesis is proposed to explain the mechanism of hyperprolactinemia associated with the pituitary stalk compression syndrome.

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John D. Pickard, Margaret Matheson, James Patterson, and David Wyper

✓ The response of cerebral blood flow (CBF) to drug-induced hypotension was measured in 20 patients who underwent craniotomy for clipping of a cerebral aneurysm following subarachnoid hemorrhage. A modified intravenous xenon-133 injection technique was used to monitor CBF. In 15 patients, CBF increased significantly with hypotension, and only one developed a late neurological deficit. In five patients, CBF fell with halothane-induced hypotension, and four developed delayed neurological deficits. Measurement of the intraoperative CBF response to halothane-induced hypotension may reveal those patients at greatest risk of developing late neurological deficits and who require more intensive postoperative monitoring and early use of the induced hypertension technique.

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Hugh K. Richards, Helen M. Seeley, and John D. Pickard


In recent years CSF shunt catheters impregnated with rifampicin and clindamycin have been introduced to the United Kingdom (UK) market. These catheters have been shown to be effective in vitro against cultures of Staphylococcus epidermidis. The authors used data collected by the UK Shunt Registry to assess the efficacy of antibiotic-impregnated catheters (AICs) against shunt infection by using a matched-pair study design.


The UK Shunt Registry contains data on nearly 33,000 CSF shunt-related procedures. The authors identified 1139 procedures in which impregnated catheters had been used, and accurate information was known about diagnosis, number of revisions, sex, and age in these cases. The database was ordered chronologically and searched forward and backward for cases with these same characteristics but involving conventional catheters. Matches were found for 994 procedures.


Among the 994 procedures in which AICs had been used, 30 shunts were subsequently revised because of shunt infection. Among the 994 controls, 47 were subsequently revised for infection (p = 0.048, chi-square test).


The UK Shunt Registry does not collect data on causative organisms, and the surgeon is relied on entirely for the diagnosis of infection. However, with the large number of matched pairs evaluated, the authors attempted to reduce bias to a minimum. Their data suggest that AICs have the potential to significantly reduce shunt infections.

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Marek Czosnyka, Piotr Smielewski, Stefan Piechnik, Luzius A. Steiner, and John D. Pickard

Object. The goal of this study was to examine the relationship between cerebral autoregulation, intracranial pressure (ICP), arterial blood pressure (ABP), and cerebral perfusion pressure (CPP) after head injury by using transcranial Doppler (TCD) ultrasonography.

Methods. Using ICP monitoring and TCD ultrasonography, the authors previously investigated whether the response of flow velocity (FV) in the middle cerebral artery to spontaneous variations in ABP or CPP provides reliable information about cerebral autoregulatory reserve. In the present study, this method was validated in 187 head-injured patients who were sedated and receiving mechanical ventilation. Waveforms of ICP, ABP, and FV were recorded over intervals lasting 20 to 120 minutes. Time-averaged mean FV and CPP were determined. The correlation coefficient index between FV and CPP (the mean index of autoregulation [Mx]) was calculated over 4-minute epochs and averaged for each investigation.

The distribution of averaged mean FV values converged with the shape of the autoregulatory curve, indicating lower (CPP < 55 mm Hg) and upper (CPP > 105 mm Hg) thresholds of autoregulation. The relationship between the Mx and either the CPP or ABP was depicted as a U-shaped curve. Autoregulation was disturbed in the presence of intracranial hypertension (ICP ≥ 25 mm Hg) and when mean ABP was too low (ABP < 75 mm Hg) or too high (ABP > 125 mm Hg). Disturbed autoregulation (p < 0.005) and higher ICP (p < 0.005) occurred more often in patients with unfavorable outcomes than in those with favorable outcomes.

Conclusions. Autoregulation not only is impaired when associated with a high ICP or low ABP, but it can also be disturbed by too high a CPP. The Mx can be used to guide intensive care therapy when CPP-oriented protocols are used.

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Erhard W. Lang, Magdalena Kasprowicz, Peter Smielewski, Edgar Santos, John Pickard, and Marek Czosnyka


The pressure reactivity index (PRx) correlates with outcome after traumatic brain injury (TBI) and is used to calculate optimal cerebral perfusion pressure (CPPopt). The PRx is a correlation coefficient between slow, spontaneous changes (0.003–0.05 Hz) in intracranial pressure (ICP) and arterial blood pressure (ABP). A novel index—the so-called long PRx (L-PRx)—that considers ABP and ICP changes (0.0008–0.008 Hz) was proposed.


The authors compared PRx and L-PRx for 6-month outcome prediction and CPPopt calculation in 307 patients with TBI. The PRx- and L-PRx–based CPPopt were determined and the predictive power and discriminant abilities were compared.


The PRx and L-PRx correlation was good (R = 0.7, p < 0.00001; Spearman test). The PRx, age, CPP, and Glasgow Coma Scale score but not L-PRx were significant fatal outcome predictors (death and persistent vegetative state). There was a significant difference between the areas under the receiver operating characteristic curves calculated for PRx and L-PRx (0.61 ± 0.04 vs 0.51 ± 0.04; z-statistic = −3.26, p = 0.011), which indicates a better ability by PRx than L-PRx to predict fatal outcome. The CPPopt was higher for L-PRx than for PRx, without a statistical difference (median CPPopt for L-PRx: 76.9 mm Hg, interquartile range [IQR] ± 10.1 mm Hg; median CPPopt for PRx: 74.7 mm Hg, IQR ± 8.2 mm Hg). Death was associated with CPP below CPPopt for PRx (χ2 = 30.6, p < 0.00001), and severe disability was associated with CPP above CPPopt for PRx (χ2 = 7.8, p = 0.005). These relationships were not statistically significant for CPPopt for L-PRx.


The PRx is superior to the L-PRx for TBI outcome prediction. Individual CPPopt for L-PRx and PRx are not statistically different. Deviations between CPP and CPPopt for PRx are relevant for outcome prediction; those between CPP and CPPopt for L-PRx are not. The PRx uses the entire B-wave spectrum for index calculation, whereas the L-PRX covers only one-third of it. This may explain the performance discrepancy.

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Aswin Chari, Marek Czosnyka, Hugh K. Richards, John D. Pickard, and Zofia H. Czosnyka


The Cambridge Shunt Evaluation Laboratory was established 20 years ago. This paper summarizes the findings of that laboratory for the clinician.


Twenty-six models of valves have been tested long-term in the shunt laboratory according to the expanded International Organization for Standardization 7197 standard protocol.


The majority of the valves had a nonphysiologically low hydrodynamic resistance (from 1.5 to 3 mm Hg/[ml/min]), which may result in overdrainage related to posture and during nocturnal cerebral vasogenic waves. A long distal catheter increases the resistance of these valves by 100%–200%. Drainage through valves without a siphon-preventing mechanism is very sensitive to body posture, which may result in grossly negative intracranial pressure. Siphon-preventing accessories offer a reasonable resistance to negative outlet pressure; however, accessories with membrane devices may be blocked by raised subcutaneous pressure. In adjustable valves, the settings may be changed by external magnetic fields of intensity above 40 mT (exceptions: ProGAV, Polaris, and Certas). Most of the magnetically adjustable valves produce large distortions on MRI studies.


The behavior of a valve revealed during testing is of relevance to the surgeon and may not be adequately described in the manufacturer's product information. The results of shunt testing are helpful in many circumstances, such as the initial choice of shunt and the evaluation of the shunt when its dysfunction is suspected.

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Marek Czosnyka, Hugh K. Richards, Helen E. Whitehouse, and John D. Pickard

✓ Clinical studies with transcranial Doppler suggest that the pulsatility of the flow velocity (FV) waveform increases when the distal cerebrovascular resistance (CVR) increases. To clarify this relationship, the authors studied animal models in which the resistance may be decreased in a controlled manner by an increase in arterial CO2 tension, or by a decrease in cerebral perfusion pressure (CPP) in autoregulating animals. Twelve New Zealand white rabbits were anesthetized, paralyzed, and ventilated. Transcranial Doppler basilar artery FV, laser Doppler cortical blood flow, arterial pressure, intracranial pressure, and end-tidal CO2 concentration were measured continuously. Cerebrovascular resistance (CPP divided by laser Doppler cortical flux) and Gosling Pulsatility Index (PI, defined as an FV pulse amplitude divided by a timed average FV) were calculated as time-dependent variables for each animal.

Four groups of animals undergoing controlled manipulations of CVR were analyzed. In Group I, arterial CO2 concentration was changed gradually from hypocapnia to hypercapnia. In Group II, gradual hemorrhagic hypotension was used to reduce CPP. In Group III, the short-acting ganglion blocking drug trimetaphan was injected intravenously to induce transient hypotension. Intracranial hypertension was produced by subarachnoid saline infusion in Group IV. During the hypercapnic challenge the correlation between the cortical resistance and Doppler flow pulsatility was positive (r = 0.77, p < 0.001). In all three groups in which cerebral perfusion pressure was reduced a negative correlation between pulsatility index and cerebrovascular resistance was found (r = −20.84, p < 0.001). The authors conclude that PI cannot be interpreted simply as an index of CVR in all circumstances.

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Marek Czosnyka, Hugh K. Richards, Zofia Czosnyka, Stefan Piechnik, and John D. Pickard

Object. The aim of the study was to assess how cerebrospinal fluid (CSF) pressure—volume compensation depends on cerebrovascular tone.

Methods. In 26 New Zealand White rabbits, intracranial pressure (ICP), arterial blood pressure, and basilar artery blood flow velocity were measured continuously. Saline was infused into the cranial subarachnoid space to assess CSF compensatory parameters: the resistance to CSF outflow, the elastance coefficient, and the amplitude of the ICP pulsatile waveform. Infusions were repeated on two different levels of CO2 concentration in the arterial blood (PaCO2), at normotension and hypotension, and after the death of the animal.

An increase in PaCO2 from a mean of 27 to 48 mm Hg was accompanied by an 18% increase in the resistance to CSF outflow (p < 0.005) and a 64% increase (p < 0.05) in the elastance coefficient. A decrease in arterial blood pressure from a mean of 100 to 51 mm Hg caused a 25% decrease in CSF outflow resistance (p < 0.01) but did not affect the elastance coefficient. Postmortem, a 23% decrease in the CSF outflow resistance was associated with a 102% decrease in the elastance coefficient.

Conclusions. Cerebrovascular parameters have a limited but significant impact on CSF infusion studies. The vascular component of ICP may be identified as a significant factor contributing to this phenomenon. During infusion studies, physiological parameters influencing vascular conditions should be maintained as stable as possible.