An investigation of structural degradation of cerebrospinal fluid shunt valves performed using scanning electron microscopy and energy-dispersive x-ray microanalysis.
OBJECTIVE
Surveys of cerebrospinal fluid (CSF) shunts that have been removed from patients have shown that even when the ventricular catheter is the cause of the obstruction, the valve may be obstructed or underperforming. The aim of this pilot study was to investigate the degradation of shunt valve structure over time due to the deposition of debris. The findings were compared with findings in unused valves.


METHODS
Scanning electron microscopy was used to visualize the structures of the valves. The items that were examined included two unused and nine explanted cylindrical medium pressure valves, one unused and six explanted Delta 1.5 valves (PS Medical, Goleta, CA), and one explanted Medos Programmable valve (Codman Johnson & Johnson, LeLocle, Switzerland). The valves were cut open, disassembled, and coated in gold. The areas that were analyzed included the main valve chamber, the diaphragm unit, and the antisiphon device. For areas with abnormal deposits, energy-dispersive x-ray microanalysis was performed to establish the chemical composition of the deposits. The reference unused valves had smooth surfaces with no deposits in any areas. All explanted valves had extensive deposits in all surveyed areas. The deposits varied from small clusters of crystals to large areas that displayed a cobblestone appearance. In diaphragm valves the deposits extensively affected the surface of the diaphragm and the gap between the diaphragm and the surrounding case, where normally CSF flows; in the Medos valve the deposits affected in the spring and "staircase" unit. Deposits were present as early as 2 weeks after implantation. On some valves there was a complete film covering the entire outlet of the valve, which formed a cast inside the valve stretching from wall to wall. The deposits consisted mostly of sodium and chloride, but occasionally contained calcium. In all infected and some noninfected valves there was a significant peak of carbon, indicating the presence of protein deposits.


CONCLUSIONS
It appears that the continuous flow of CSF through shunt valves causes surface deposits of sodium chloride and other crystals on all aspects of the valve, including the outlet pathways. The formation of deposits may be encouraged by the adhesive properties of the materials that constitute the valve parts.
Sgouros
Spyros
S
Department of Neurosurgery, Birmingham Children's Hospital, United Kingdom. S.Sgouros@bham.ac.uk
Dipple
Susan J
SJ
D001921:Brain / Q000382:microbiology / Q000601:surgery; D002408:Catheters, Indwelling / Q000382:microbiology; D002557:Cerebrospinal Fluid Shunts / Q000009:adverse effects / Q000295:instrumentation; D002648:Child; D004577:Electron Probe Microanalysis / Q000295:instrumentation; D004867:Equipment Design; D004868:Equipment Failure; D006801:Humans; D006849:Hydrocephalus / Q000382:microbiology / Q000601:surgery*; D008855:Microscopy, Electron, Scanning; D011183:Postoperative Complications