T he technique of endoscopic third ventriculostomy (ETV) has been under close evaluation as a treatment option for obstructive hydrocephalus. Although early on the procedure was associated with a very high, unacceptable complication rate, 41 more recent publications have reported success rates of about 70% and low complication rates, including mortality, around 0.5%-1.0%. 9,13,20,31,35 Nowadays, ETV is accepted as the gold standard for treatment of obstructive hydrocephalus. In comparison with ventriculoperitoneal shunting, a significantly lower complication rate and reoperation rate in the long term is expected. 2,10,26 Nevertheless, topics such as the prediction of ETV success, 4,12,26,28,42 period of highest failure rate, 26 and late deterioration after ETV 7,29 are still topics of discussion. However, current data are scarce, and the long-term efficacy of ETV is often under debate, since most studies have reported a rather short follow-up period, e.g., 8 months 13 or a few years. 1,22,23,40 Very few studies exist with a significantly longer follow-up, e.g., 4 years. 35This study investigates very long term success rates, up to 16 years, and the incidence of failures in the early and long-term postoperative periods after ETV. Methods Study DesignThe long-term outcome of ETV was evaluated through a retrospective analysis of all patients who underwent an abbreviatioN ETV = endoscopic third ventriculostomy. SubMitteD February 22, 2014. accepteD November 25, 2014. iNcluDe wheN citiNg Published online July 31, 2015; DOI: 10.3171/2014.11.JNS14414. DiScloSure J. Oertel reports that he is a consultant for Karl Storz Co. The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper. obJect Endoscopic third ventriculostomy (ETV) is the procedure of choice in the treatment of obstructive hydrocephalus. The excellent clinical and radiological success rates are well known. Nevertheless, very few papers have addressed the very long term outcomes of the procedure in very large series. The authors present a large case series of 113 patients who underwent 126 ETVs, and they highlight the initial postoperative outcome after 3 months and long-term follow-up with an average of 7 years. MethoDS All patients who underwent ETV at the Department of Neurosurgery, Mainz University Hospital, between 1993 and 1999 were evaluated. Obstructive hydrocephalus was the causative pathology in all cases. reSultS The initial clinical success rate was 82% and decreased slightly to 78% during long-term follow-up. Longterm success was analyzed using Kaplan-Meier curves. Overall, ETV failed in 31 patients. These patients underwent a second ETV or shunt treatment. A positive impact on long-term success was seen for age older than 6 months, and for obstruction due to cysts or benign aqueductal stenosis. The complication rate was 9% with 5 intraoperative and 5 postoperative events. coNcluSioNS The high clinical success rate in short-term and long-term follow-up confirms ETV's s...

OBJECTIVEThe use of subdural drains after surgical evacuation of chronic subdural hematoma (CSH) decreases the risk of recurrence and has become the standard of care. Halfway through the controlled, randomized TOSCAN (Randomized Trial of Follow-up CT after Evacuation of Chronic Subdural Hematoma) trial, the authors’ institutional guidelines changed to recommend subgaleal instead of subdural drainage. The authors report a post hoc analysis on the influence of drain location in patients participating in the TOSCAN trial.METHODSThe study involved 361 patients enrolled in the TOSCAN trial. The patients were stratified according to whether they received surgery before (cohort A) or after (cohort B) the change in institutional protocol. An intention-to-treat analysis was performed with surgery for recurrence as the primary endpoint. Secondary endpoints were outcome-based on modified Rankin Scale scores, seizures, infections, parenchymal brain injuries, and hematoma diameter.RESULTSOf the 361 patients included in the analysis, 214 were stratified into cohort A (subdural drainage recommended), while 147 were stratified into cohort B (subgaleal drainage recommended). There was a 31.78% rate of crossover from the subdural to the subgaleal drainage insertion site due to technical or anatomical difficulties. No differences in the rates of reoperation (21.5% [cohort A] vs 25.17% [cohort B], OR 0.81, 95% CI 0.50–1.34, p = 0.415), infections (0.47% [cohort A] vs 2.04% [cohort B], OR 0.23, 95% CI 0.02–2.19, p = 0.199), seizures (3.27% [cohort A] vs 2.72% [cohort B], OR 1.21, 95% CI 0.35–4.21, p = 0.765), or favorable outcomes (modified Rankin Scale score 0–3) at 1 and 6 months (91.26% [cohort A] vs 96.43% [cohort B], OR 0.39, 95% CI 0.14–1.07, p = 0.067; 89.90% [cohort A] vs 91.55% [cohort B], OR 0.82, 95% CI 0.39–1.73, p = 0.605) were noted between the two cohorts. Postoperatively, patients in cohort A had more frequent parenchymal brain tissue injuries (2.8% vs 0%, p = 0.041). Postoperative absolute and relative hematoma reduction was similar irrespective of the location of the drain.CONCLUSIONSSubgaleal rather than subdural placement of the drain did not increase the risk for reoperation for recurrence of CSHs, nor did it have a negative impact on clinical or radiological outcome. The intention to place a subdural drain was associated with a higher rate of parenchymal injuries.

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This new telemetric system was safe and effective for ICP measurement over a long period, including home monitoring. For the patients, it was easy to handle, and reliable data could be recorded over many weeks. Based on this preliminary experience, the authors consider the new system extremely advantageous in surgical decision making in particularly difficult cases of suspected abnormalities of ICP.

The postoperative adjustability of the opening pressure level is the advantage of the new gravitational valve. The good clinical outcome is attributed to the new valve technology. The proSA appears to be a promising shunt valve to overcome overdrainage in adolescent and adult hydrocephalus patients.

Endoscopic opening of the lamina terminalis via a transventricular transforaminal route appears to be feasible. No complications were observed. Although no conclusions on the clinical success rate can be drawn, the reliable anatomical opening and known success rate for anterior subfrontal approaches suggest that the technique represents an alternative in a small subgroup of patients in whom a standard ETV cannot be performed.

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Background: Delayed cerebral infarction after aneurysmal subarachnoid hemorrhage (aSAH) still remains the leading cause of disability in patients that survive the initial ictus. It has been shown that CT perfusion (CTP) imaging can detect hypoperfused brain areas. The aim of this study was to evaluate if a single acute CTP examination at time of neurological deterioration is sufficient or if an additional baseline CTP increases diagnostic accuracy. Methods: Retrospective analysis of acute and baseline (within 24 hours after aneurysm treatment) CTP examinations of patients with neurological deterioration because of vasospasm-related hypoperfusion. Patients without clinical deterioration during the vasospasm period served as controls. The following CTP parameters were analyzed for predefined brain regions: time to drain (TTD), mean transit time, time to peak, cerebral blood flow and volume. Results: 33 patients with and 23 without neurological deterioration were included. Baseline CTP examination did not ameliorate diagnostic accuracy of the acute CTP examination in symptomatic patients. The same was true for inter-hemispheric comparison of perfusion parameters of the acute examination. The CTP parameter with the highest diagnostic yield was TTD of the symptomatic brain region (threshold value 4.7 sec, sensitivities 97 %, specificities 96 %). Conclusions: Acute CTP examination in case of suspected vasospasm-induced neurological deterioration after aSAH has the highest diagnostic accuracy to detect misery perfusion.