Acta Neurochirurgica (2020) 162:15–21

https://doi.org/10.1007/s00701-019-04088-9

ORIGINAL ARTICLE - CSF CIRCULATION

Flow-regulated versus differential pressure valves for idiopathic

normal pressure hydrocephalus: comparison of overdrainage rates
and neurological outcome
Christian Wetzel 1 & Lukas Goertz 1 & Philipp Noé 1,2 & Niklas von Spreckelsen 1,3 & Marina Penner 1 &
Christoph Kabbasch 4 & Roland Goldbrunner 1 & Boris Krischek 1

Received: 15 July 2019 / Accepted: 24 September 2019 / Published online: 12 November 2019
# Springer-Verlag GmbH Austria, part of Springer Nature 2019

Abstract
Background To compare flow-regulated (FR) and differential pressure (DP) valves for treatment of patients with idiopathic
normal hydrocephalus (iNPH) focusing on overdrainage and neurological outcome.
Methods This is a retrospective study of patients with iNPH treated with FR and DP valves at a single institution between 2008
and 2018. The neurological status was evaluated retrospectively with the Kiefer scale at baseline, after shunt placement and at the
6-month follow-up. Groups were compared using inverse probability of treatment weighting based on propensity scores.
Results The study cohort consisted of 38 patients treated with FR valves and 49 with DP valves. The mean patient age was 72.0 ±
7.6 years. Based on the Kiefer scale score, neurological improvement at the 6-month follow-up was recorded in 79.6% in the DP
group and 89.5% in the FR group (p = 0.252). The overdrainage rates were higher among DP valves (10.2%) than among FR
valves (2.6%, adjusted p = 0.002). Valve malfunction occurred in 2.0% in the DP group and 5.3% in the FR group (adjusted p =
0.667).
Conclusions The current study demonstrates a comparable neurological improvement between DP and FR valves, with poten-
tially lower overdrainage rates among FR valves. Long-term studies will be necessary to draw a definite conclusion on FR valves
for treatment of iNPH patients.

Keywords Differential pressure valve . Flow-regulated valve . iNPH . Normal pressure hydrocephalus . Overdrainage

Christian Wetzel and Lukas Goertz contributed equally to this work.
This article is part of the Topical Collection on CSF Circulation
* Lukas Goertz
lukas.goertz@uk-koeln.de
1 symptoms of iNPH are known as Hakim’s triad and consist
Faculty of Medicine and University Hospital, Center for
Neurosurgery, University of Cologne, Kerpener Strasse 62,
50937 Cologne, Germany
2
Department of Neurosurgery, Bundeswehrkrankenhaus Koblenz,
Rübenacher Strasse 170, 56072 Koblenz, Germany
3
Harvey Cushing Neuro-Oncology Laboratories, Department of
Neurosurgery, Brigham and Women’s Hospital, Harvard Medical
School, 75 Francis Street, Boston, MA 02115, USA
4
Department of Neuroradiology, University Hospital of Cologne,
Kerpener Strasse 62, 50937 Cologne, Germany
Introduction
Idiopathic normal pressure hydrocephalus (iNPH) is a brain
disease of unknown origin, most prevalent in elderly patients.
It is a subtype of chronic hydrocephalus and characterized by
enlarged cerebral ventricles, in which the intracranial pressure
remains normal or only slightly elevated [6]. The cardinal
of magnetic gait, cognitive impairment, and urinary inconti-
nence [1]. Further common symptoms include headache and
dizziness.
Although intracranial pressure is usually not elevated, per-
manent drainage of cerebrospinal fluid (CSF) by a
ventriculoperitoneal (VP) shunt represents an effective treat-
ment option for iNPH. Programmable differential pressure
(DP) valves are the most frequently used valve types for
iNPH, achieving symptom improvement in more than 80%
16
of the patients in benchmark cohorts [2, 11]. The major ad-
vantage of programmable valves consists of the non-invasive
adjustment of the opening pressure by an external magnetic
field, which allows to adjust the optimal drainage rates on an
individual basis and to counteract overdrainage by increasing
the outflow resistance non-invasively [2, 5]. If necessary, the
adjunctive use of anti-siphon devices (ASD) or gravitational
units further reduces overdrainage rates by providing a vari-
able outflow resistance dependent on patient position, thus
addressing the posture-related changes of the drainage rates.
In clinical studies, ASDs and gravitational units were associ-
ated with severe overdrainage rates of 5% while maintaining
good clinical outcomes [3, 7, 12, 14]. Using DP valves, ad-
justments are necessary in around 50% of patients and can be
time-consuming, which represents a potential drawback of
these valve types [4, 10].
The use of non-programmable flow-regulated valves such as
the Integra® NPH low flow valve (Integra LifeSciences,
Plainsboro, NJ, USA) may address this limitation; however,
clinical data on this valve type is rare. The Integra® NPH low
flow valve has a flow-regulated, self-regulatory mechanism with
reduced drainage rates (8–17 ml/h) in comparison to standard
flow-regulated valves (e.g., OSV Sigma valve 18–30 ml/h)
which have been adjusted specifically for iNPH patients [16]. It
provides a variable resistance to the CSF outflow with the aim to
minimize overdrainage by maintaining constant drainage rates
independent of patient position or differential pressure.
The objective of the current study was to retrospec-
tively compare differential pressure and flow-regulated
valves in terms of neurological outcome, valve-related
complications, and overdrainage rates. To address a po-
tential selection bias, we performed an inverse probabil-
ity of treatment weighting (IPTW) adjustment based on
the propensity score model.
Methods
This is a retrospective review of consecutive patients that
underwent VP-shunt placement for iNPH at a high-
volume German university hospital during January 2008
and November 2018. During this period, three different
va lve ty pe s we re us ed: (1 ) Co dma n® H ak im®
Programmable Valve (Integra LifeSciences, Plainsboro,
NJ, USA), (2) Sophy® SM8 valve (Sophysa, Orsay,
France), and (3) Integra® NPH low flow valve (Integra
LifeSciences, Plainsboro, NJ, USA). While the
Codman® Hakim® and the Sophy® SM8 valves are
both programmable differential pressure valves, the
Integra® NPH low flow valve is a non-programmable
flow-regulated valve. Since the Codman® Hakim® valve
is used more frequently than the Sophy SM8 valve in
international studies on iNPH [11], we compared
Acta Neurochir (2020) 162:15–21
outcomes between the Codman® Hakim® and the
Integra® NPH low flow valves. A local ethics committee
approval (No. 12–197) was obtained for the use of the
Integra® NPH low flow valve for clinical routine. For
this specific retrospective study with anonymized analy-
sis of patient data, an separate ethics committee approval
was waived according to the statutes of our institutional
guidelines.
Inclusion and exclusion criteria
All iNPH patients that were either treated with the Codman®
Hakim® valve or the Integra® NPH low flow valve and that
had presented for their 6-month follow-up were enrolled.
There was no specific exclusion criterion in the present study.
Procedure
The diagnosis of iNPH and indication for shunt surgery
was made based on the clinical and radiological consider-
ations. The presence of at least two cardinal symptoms of
iNPH (broad based and magnetic gait, cognitive impair-
ment, and urinary incontinence) was regarded as indica-
tive for iNPH. Radiological signs compatible with iNPH
such as symmetrical ventriculomegaly and subarachnoid
space tightness with an Evans’ index > 0.3 were a prereq-
uisite for shunt placement.
Patients with a questionable diagnosis of iNPH received a
supplementary diagnostic testing by placement of a lumbar
drain for 3 days. In case of positive response to extended
lumbar drainage, shunt surgery was indicated.
For patients receiving a DP valve, an implantation of an
additional anti-siphon device was performed at the neurosur-
geon’s discretion.
Patient evaluation
The following data was collected retrospectively from the
medical records: age, gender, clinical symptoms, duration of
symptoms, neurological status, and complications. All pa-
tients received a complete neurological examination by a qual-
ified neurosurgeon at baseline, at discharge and at follow-up
visits according to institutional guidelines. The functional sta-
tus was assessed with the modified Rankin scale (mRS). The
mRS had originally been developed to assess functional out-
come after stroke [15]; however, it has also been used to eval-
uate the outcome of iNPH patients [11].
We further determined the Kiefer scale (KS) score at
baseline and at the 6-month follow-up. The KS repre-
sents an established and routinely used instrument for
Acta Neurochir (2020) 162:15–21
retrospective analysis of iNPH severity and neurological
outcome after shunt surgery [9, 12]. It scores the severity
of the three cardinal symptoms of iNPH (gait distur-
bance, cognitive impairment, and urinary incontinence)
and two additional symptoms (headache and dizziness).
The overall KS score ranges from 0 to 24, whereby
higher values represent a more severe impairment.
Clinical improvement of the patient’s neurological status
was evaluated by the NPH recovery rate (NPH-RR),
which is calculated based on the preoperative and
follow-up KS scores using the following formula:
preoperative KS score−postoperative KS score
NPH−RR ¼ *10
preoperative KS score
Based on the NPH-RR, the neurological outcome was clas-
sified as follows: < 2 points: poor, 2–4 points: satisfactory, 5–6
points: good, and 7–10 points: excellent.
In the present study, we only report valve-related compli-
cations that required surgical revision, such as subdural
hygroma/hematoma and valve malfunction. Subdural fluid
collections that were indicative for overdrainage but could
be treated conservatively by incrementing the outflow resis-
tance were not regarded as complications.
Statistical analysis
Qualitative parameters were presented as numbers and
frequencies and compared with the chi-square and
Fisher exact tests, when appropriate. Quantitative vari-
ables were presented as means ± standard deviation and
compared with the unpaired two-sided Student t test
(normally distributed data) or the Mann–Whitney U test
(non-normally distributed data). Quantitative variables
were tested for normality using the Shapiro–Wilk test.
An inverse probability of treatment weighting (IPTW)
approach based on the propensity score model was used
as a statistical technique to create two synthetic study
groups with comparable propensity scores, in which
treatment assignment is independent of measured base-
line characteristics. This method aims to minimize a po-
tential selection bias and to obtain comparative estimates
of treatment effects. Propensity scores were calculated
using a multivariate logistic regression model with
flow-regulated valves as the response and the following
covariates: age, sex, duration of symptoms, presence of
gait disturbance, cognitive impairment, urinary inconti-
nence, headache and dizziness, preoperative mRS score,
and preoperative KS score. All statistic tests were per-
formed using SPSS Version 25.0 for Windows (IBM
SPSS Statistics for Windows, Version 25.0, Armonk,
17
NY, USA). A p value < 0.05 was considered as statisti-
cally significant.
Results
Patient characteristics
A total of 87 iNPH patients met the inclusion criteria and were
enrolled in this study. Among those, 49 patients were treated
with the Codman® Hakim® valve (DP group, 49/87, 56.3%)
and 38 with the Integra® NPH low flow valve (FR group, 38/
87, 43.7%). In the DP group, an additional ASD was im-
planted in 23 patients (46.9%). In the overall population, the
mean patient age was 72.0 ± 7.6 years (range 53–87 years),
including 24 females and 63 males. Of 87 patients, 86 (98.9%)
presented with gait disturbance, 77 (88.5%) with cognitive
impairment and 70 (80.5%) with urinary incontinence. The
mean duration of symptoms before surgery was 23.3 ±
20.4 months (range 2–96 months). The mean preoperative
mRS score was 3.0 ± 0.8 (range 2–4), and the mean KS score
was 7.1 ± 2.0 (range 3–12). Baseline patient characteristics
were not significantly different between the DP and the FR
groups, as outlined in Table 1. Although there were no signif-
icant differences in baseline characteristics, we performed an
additional IPTW analysis based on the propensity score model
to address a potential selection bias. Baseline patient charac-
teristics after IPTW adjustment are shown in Table 1. In the
DP group, baseline characteristics among patients treated with
and without an additional ASD were comparable, as listed in
Table 2.
Neurological outcome
The mean KS score at baseline was 7.1 ± 2.1 in the DP
group and 7.2 ± 1.9 in the FR group (p = 0.815). At the 6-
month follow-up, there was no significant difference in the
KS scores after DP (3.9 ± 2.9) and FR (3.4 ± 2.4) valve
implantation (p = 0.413). This difference remained insig-
nificant after IPTW adjustment (0.453). The mean NPH-
RRs were similar for the Codman® Hakim® valve (4.6 ±
4.0) and the Integra® NPH low flow valve (5.3 ± 3.3; p =
0.395), even when adjusting for the propensity score (p =
0.236). Seventy-three (83.9%) patients had a recovery rate
of at least 2 points, 79.6% (39/49) in the DP group and
89.5% (34/38) in the FR group (p = 0.252). Excellent out-
come (7–10 points) was achieved in 40.2% (35/87). A
slightly higher portion of patients in the FR group (18/38,
47.4%) achieved excellent outcome in comparison to the
DP group (17/49, 34.7%); however, this difference did not
receive statistical significance, neither in the unadjusted
(p = 0.232) nor in the adjusted analysis (p = 0.170).
18 Acta Neurochir (2020) 162:15–21

Table 1 Baseline patient characteristics

Characteristic DP valve (N = 49) FR valve (N = 38) P IPTW adjustment

DP valve (N = 76) FR valve (N = 73) Adjusted P

Patient age (years) 72.6 ± 6.9 71.1 ± 8.4 0.347 72.7 ± 6,5 72.4 ± 7.7 0.791
Sex 0.463 0.894
Female 12 (24.5%) 12 (31.6%) 17 (22.4%) 17 (23.3%)
Male 37 (75.5%) 26 (68.4%) 59 (77.6%) 56 (76.7%)
Duration of symptoms (months) 22.6 ± 23.2 23.9 ± 17.4 0.789 23.2 ± 21.4 24.0 ± 19.0 0.841
Gait disturbance 48 (98.0%) 38 (100%) 1.0 75 (98.7%) 73 (100%) 1.0
Cognitive impairment 44 (89.8%) 33 (86.8%) 0.668 68 (89.5%) 65 (89.0%) 0.932
Incontinence 40 (81.6%) 30 (78.9%) 0.754 63 (82.0%) 63 (86.3%) 0.565
Headache 6 (12.2%) 3 (7.9%) 0.726 7 (9.2%) 4 (5.5%) 0.534
Dizziness 6 (12.2%) 7 (18.4%) 0.423 9 (11.8%) 9 (12.3%) 0.927
Preoperative mRS score 3.0 ± 0.8 3.1 ± 0.8 0.581 2.9 ± 0.8 3.0 ± 0.7 0.643
Preoperative Kiefer Scale score 7.1 ± 2.1 7.2 ± 1.9 0.815 7.1 ± 2.0 7.2 ± 1.7 0.655

DP differential pressure, FR flow-regulated, IPTW inverse probability of treatment weighting, mRS modified Rankin scale

In the overall population, the mean improvement in the
mRS score at 6-month follow-up was 1.1 ± 0.9 points, 1.1 ±
1.0 points in the DP group and 1.1 ± 0.8 points in the FR
group (p = 0.861).
A systematic overview of neurological outcome after DP
and FR valve implantation is given in Table 3.
In the DP group, there is no significant difference among
patients treated with and without an additional ASD in terms
of outcome parameters, as listed in Table 2.
Overdrainage and valve malfunction
Within the 6-month FU duration, subdural effusions that
required surgical evacuation occurred in 5 of the 49
patients of the DP group (10.2%), compared with one of
38 patients in the FR group (2.6%). This difference was
statistically significant after IPTW adjustment (p = 0.002).
Moreover, in the DP group, there were three subdural
fluid collections (6.1%) that were managed conservatively
by incrementing the outflow resistance. The treatment did
not require surgery.
Valve malfunction within the 6-month follow-up period
was observed in one patient in the DP group (2.0%) and
two patients in the FR group (5.3%, p = 0.578, adjusted
p = 0.667). In all three cases, the patients improved clini-
cally after initial VP placement and symptoms worsened
thereafter. Valve malfunction was confirmed intraopera-
tively, respectively.

Table 2 Baseline characteristics

and outcome of patients treated by Characteristic DP with ASD (N = 23) DP without ASD (N = 26) P
a differential pressure (DP) valve
in combination with or without an Patient age (years) 73.1 ± 5.7 72.1 ± 7.9 0.640
anti-siphon device (ASD) Sex 0.674
Female 5 7
Male 18 19
Duration of symptoms (months) 24.1 ± 24.8 21.5 ± 22.4 0.746
mRS score
Preoperative 2.9 ± 0.8 3.0 ± 0.8 0.705
6-month FU 2.0 ± 1.2 1.7 ± 1.1 0.421
Kiefer scale score
Preoperative 7.3 ± 2.2 6.9 ± 2.1 0.499
6-month FU 4.3 ± 3.2 3.5 ± 2.5 0.359
NPH-RR 4.2 ± 4.7 4.9 ± 3.4 0.518
Overdrainage 3 2 0.655

mRS modified Rankin scale, FU follow-up, NPH-RR normal pressure hydrocephalus recovery rate
Acta Neurochir (2020) 162:15–21 19

Table 3 Neurological outcome

Characteristic DP valve (N = 49) FR valve (N = 38) P Adjusted P

mRS score
Preoperative 3.0 ± 0.8 3.1 ± 0.8 0.581 0.643
6-month FU 1.9 ± 1.2 1.9 ± 1.0 0.873 0.642
Kiefer scale score
Preoperative 7.1 ± 2.1 7.2 ± 1.9 0.815 0.655
6-month FU 3.9 ± 2.9 3.4 ± 2.4 0.413 0.453
NPH-RR 4.6 ± 4.0 5.3 ± 3.3 0.395 0.236
Poor (< 2 points) 10 (20.4%) 4 (10.5%) 0.252 0.189
Satisfactory (2–4 points) 17 (34.7%) 12 (31.6%) 0.760 0.395
Good (5–6 points) 5 (10.2%) 4 (10.5%) 1.0 0.734
Excellent (7–10 points) 17 (34.7%) 18 (47.4%) 0.232 0.170

DP differential pressure; FR flow-regulated; mRS modified Rankin scale; FU follow-up; NPH-RR normal pres-
sure hydrocephalus recovery rate

Discussion idiopathic normal pressure hydrocephalus in adults) tri-

In the current study, we compared patients that were treat-
ed with a DP or a FR valve for iNPH. To minimize a
potential selection bias, we performed an additional
IPTW analysis, which ensures comparable study groups
and strengthens the validity of our results. We could show
that FR valves were associated with a potentially lower
overdrainage rate than DP valves, with similar neurolog-
ical improvement rates and a comparable portion of valve
dysfunction at 6-month follow-up.
Overdrainage
Among DP valves, the overall overdrainage rate was
16.9% (8/49). Likewise, the incidence of subdural hema-
toma or hygroma—probably due to overdrainage—
occurred in 17 of 115 patients (15%) after implanting
the Codman® Hakim® valve in the benchmark cohort
of the European Multicentre Study on iNPH [11]. In
the cited study, only one patient required surgical evac-
uation of the hematoma (0.9%), while overdrainage was
treated conservatively in the remaining patients by
incrementing the outflow resistance of the DP valve
[11]. In our study, surgical evacuation for subdural fluid
collections was necessary in 5 patients with DP valves
(10.2%), whereas 3 were managed conservatively.
To address the intracranial pressure drop during pos-
tural changes, the differential pressure shunt can be im-
planted in combination with anti-siphon devices or an
implemented gravitational unit, which compensate for
differences in the hydrostatical pressure. In the
SVASONA (shunt valves plus shunt assistant versus
shunt valves alone for controlling overdrainage in
al, gravity-assisted differential pressure valves were as-
sociated with significantly reduced overdrainage rates
(6.8%) when compared with conventional differential
pressure valves (40.8%) [12]. Likewise, Suchorska
et al. reported a subdural hygroma rate of 12.5% among
differential pressure valves compared to 0% in gravity-
assisted valves [14].
Bozhkov et al. analyzed the beneficial impact of flow-
regulated anti-siphon devices regarding overdrainage in
patients with iNPH [3]. DP valves were associated with
a lower incidence of overdrainage, when they were im-
planted in combination with an anti-siphon device (0/19)
if compared with DP valves without an ancillary device
(3/21) [3]. In the present study, there was no significant
difference in overdrainage rates between patients treated
by a DP valve with an additional ASD or by a DP valve
alone.
In contrast, FR valves were associated with a 2.6%-
overdrainage rate, which was significantly lower compared
with DP valves (p = 0.002). Moreover, these results compare
favorably to benchmark cohorts in the available literature and
are at least on par with gravitational valve types as cited above
[7, 12, 14].
A further potential advantage of FR valves is that
they have a self-regulatory mechanism of CSF drainage;
hence, there is no need for valve pressure adjustments.
Among DP valves, frequent adjustments of the valve
settings are often necessary to identify the optimal out-
flow resistance for each individual remains common in
clinical practice and can be time-consuming [8].
Moreover, changes of the valve settings after MRI ex-
aminations occur in up to 40% [4], hence requiring
verification of the valve settings by a mobile device or
by x-ray afterwards [8, 10]. For instance, valve
20
adjustments were performed in 37.8% of patients with
gravity-assisted valves in the SVASONA trial, compared
with 40.8% in patients with programmable valves [12].
Our study showed that the risk of subdural hematoma is
exceptionally low among FR valves, although there is
no possibility to change the valve settings.
Efficacy and complications
In order to evaluate the neurological outcome after FR valve
implantation, we compared patients with FR and DP valves
using the Kiefer scale. The symptoms were self-reported and
assessed retrospectively; hence, our study certainly has an
inherent measurement bias. However, the Kiefer scale repre-
sents a valid and frequently used assessment tool for neuro-
logical outcome of iNPH patients [9, 12]. The results show a
comparable neurological improvement rate for FR valves
(89.5%) and DP valves (79.6%, p = 0.252). These data are in
line with previous studies on iNPH. In the European
Multicentre Study on iNPH, neurological improvement was
obtained in 84% for programmable DP valves [11]. Likewise,
Shaw et al. reported improvement in 85% in a single-center
analysis on DP valves [13]. Suchorska et al. reported an im-
provement rate of 92% for gravity-assisted valves and 50% for
DP valves [14]. In the study by Bozhkov et al., clinical im-
provement was reported in 78.9% for DP valves in combina-
tion with a flow-regulated ASD and in 44.4% in patients treat-
ed with a DP valve alone [3].
In the current study, valve malfunctions occurred in 2 pa-
tients (5.3%) in the FR group and 1 patient in the DP group
(2.0%). In all three cases, the patients improved neurologically
after initial shunt surgery and deteriorated again within the 6-
month follow-up period. Valve dysfunction was confirmed in
all cases intraoperatively. In comparison, valve malfunction
was reported in 4.3% within a follow-up period of 12 months
in the European multicentre study on iNPH [11] and in 1.4%
for gravity-assisted valves and 4.2% for DP valves in the
SVASONA trial [12].
Limitations
The limitations of the present study are mainly related to its
retrospective, single-center design. Hence, the number of en-
rolled patients is only moderate, and we cannot exclude a
potential selection bias. To mitigate this limitation—at least
in part—we performed an IPTW analysis based on the pro-
pensity score model. Moreover, we only report 6-month fol-
low-up data; thus, the long-term effectiveness of FR valves
remains unclear.
Acknowledging the limitations of the present study, our
findings have to be interpreted with caution and cannot yet
Acta Neurochir (2020) 162:15–21
be generalized. However, our preliminary data appear prom-
ising and indicate a reasonable safety profile for FR valves,
hence justifying further examination of the use of FR valves
for iNPH. Ultimately, a prospective comparative study with
long-term data will be necessary to define the role of the
Integra NPH low flow valve for treatment of iNPH and wheth-
er it can bear comparison with gravitational valves.
Conclusions
The current study demonstrates a potentially lower
overdrainage rate of FR valves when compared with con-
ventional DP valves without compromising treatment ef-
ficacy. The neurological improvement rates were ≥ 80%
for FR and DP valves, respectively. Moreover, there was
no significant difference in valve malfunctions among
both valve types within a 6-month follow-up period.
Long-term clinical data will be necessary to follow-up
on this these conclusions.
Funding information This study was supported by a grant provided by
Integra® LifeSciences (Integra LifeSciences Services, Lyon, France).
Compliance with ethical standards
Conflict of interest The authors declare that they have no conflict of
interest.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the institu-
tional and/or national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical standards.
For this type of study formal consent is not required.
Informed consent Informed consent was obtained from all individual
participants included in the study.
Disclaimer The sponsor had no role in the design or conduct of this
research.
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Kiefer M, Eymann R, Schuhmann MU, Speil A (2013) Safety and
London, UK
efficacy of gravitational shunt valves in patients with idiopathic
normal pressure hydrocephalus: a pragmatic, randomised, open la-
bel, multicentre trial (SVASONA). J Neurol Neurosurg Psychiatry This is an interesting retrospective single-institution study comparing
84:850–857 FR and DP valves for the treatment of iNPH. The paper is well-
13. Shaw R, Everingham E, Mahant N, Jacobson E, Owler B (2016)
written, rigorously designed, and has meaningful conclusions.
Clinical outcomes in the surgical treatment of idiopathic normal
pressure hydrocephalus. J Clin Neurosci 29:81–86 Though this topic has previously been discussed in the literature, this
14. Suchorska B, Kunz M, Schniepp R, Jahn K, Goetz C, Tonn J, strong manuscript adds further evidence for readers.
Peraud A (2015) Optimized surgical treatment for normal pressure
hydrocephalus: comparison between gravitational and differential
Ali S. Haider
pressure valves. Acta Neurochir 157:703–709
15. Sulter G, Steen C, De Keyser J (1999) Use of the Barthel Chicago, USA
index and modified Rankin scale in acute stroke trials.
Stroke 30:1538–1541
16. Wetzel C, Goertz L, Schulte AP, Goldbrunner R, Krischek B (2018) Publisher’s note Springer Nature remains neutral with regard to jurisdic-
Minimizing overdrainage with flow-regulated valves - initial results tional claims in published maps and institutional affiliations.