To assess the complications related to endoscopic third ventriculostomy (ETV) and the strategies for avoiding them, a retrospective analysis of 100 consecutive ETVs performed between 1997 and 2007 was conducted. The patient ages ranged between 1 day and 69 years. The overall success rate was 73%. We experienced 7 complications (one case of arterial bleeding from basilar artery or its branch, two intraventricular hemorrhages, one case of diabetes insipidus, and one case of septic meningitis) in 6 cases. There were no cases of permanent morbidity or death. All 6 cases with complications were hydrocephalus in the pediatric population and 4 of them were under 1 year of age. In one patient case suffering from a serious vascular injury, perforation of the floor of the third ventricle was performed utilizing an electrode probe. Accordingly, our strategies to avoid the vascular complications are as follows : 1) do not use an electrode probe for ETV ; 2) careful placement of the sheath and irrigation with lactated Ringer's solution, which may play an essential role for intraoperative management of vascular injuries.

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Hematoma evacuation is generally accepted as a standard treatment for intracerebral hemorrhage (ICH). The least invasive surgical technique should be chosen to achieve the optimum outcome. Endoscopy is a minimally invasive surgery but various surgical complications have been reported, with the most serious being intra- or postoperative hemorrhage. The causes of bleeding associated with surgery can be classified into patient factors and surgical factors. The patient factors include the presence of vascular abnormalities such as ruptured aneurysm, arteriovenous malformations, etc., and coagulopathy with systemic disease. These factors are all contraindications for surgery, because of the high risk of intraoperative bleeding, and require adequate evaluation before the operation. The surgical factors include relative inexperience of the operator. The endoscope is a specialized surgical instrument. Surgeons must master the basic techniques of making the burr hole, tapping the hematoma, evacuating the hematoma, and hemostasis. Such experience is best obtained under the supervision of an expert. The society for neuroendoscopy should develop suitable educational programs such as hands-on seminars.

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Recent optical technology has improved the quality of neuroendoscopy images, which has opened more opportunities for us to perform various neuroendoscopic surgeries in our daily practice. A survey by The Japanese Society of Neuroendoscopy has detailed the current situation of neuroendoscopic surgery in Japan. Although most university hospitals had some experience with this modality of treatment, each of them still had only a few cases a year. We reviewed complications we encountered related to neuroendoscopic procedures and analyzed the causes of those events. We also summarized previous training courses and expressed our thoughts on a desired training system on neuroendoscopy.

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Neuroendoscopic surgery is performed using two-dimensional video monitors, which lack depth sensation thereby reducing virtual hand-eye co-ordination. So special training is required and different techniques than those used in other forms of microsurgery must be employed. Recently, various neuroendoscopic procedures such as third ventriculostomy, transsphenoidal surgery, evacuation of intracerebral hematoma, and so on, have been developed, but cases with severe complications have been reported sporadically. So the Japanese Society for Neuroendoscopy has organized a committee to establish a guideline and a technical certification system to develop safe neuroendoscopic surgeries. The guideline recommends that all novice neuroendoscopic surgeons only performe surgeries under the supervision of an experienced neuroendscopist and only after they have completed special training courses at hands-on seminars. Applicants for the technical certification are required to attend at least two separate of hands-on seminars and should master the basic knowledge of the instruments and common techniques necessary for performing neuroendoscopic surgeries including how to avoid and deal with complications. Then one can apply for the technical certification with at least 10 cases of experience as an assistant and 10 as an operator with an experienced neuroendoscopist. Categories include third ventriculostomy, transsphenoidal surgery, evacuation of intracerebral hematoma, endoscope-assisted microsurgery, or other neuroendoscopic surgeries. As this technical certification program requires only the basic knowledge and common techniques for neuroendoscopic surgeries in general, an advanced certification program for each category is under consideration.

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We treated six cases with expanded polytetrafluoroethylene (ePTFE) sheet as an artificial dura mater in whom postoperative infection and refractory skin fistula developed after craniotomy. The ePTFE sheet and bone flap were removed completely. Every case showed a membrane that formed beneath the ePTFE sheet. The dura mater was not replaced in three cases and it was replaced with a fascia lata graft in three cases. Postoperative infection developed in one case where the dura mater was replaced with a fascia lata graft. Staged cranioplasty with hydroxyapatite was performed in five cases. Postoperative subcutaneous cerebrospinal fluid collection occurred after the staged cranioplasty in one case where the membrane beneath the ePTFE sheet was damaged during debridement. None of the patients showed continuous cerebrospinal fluid leakage after the removal of the ePTFE sheet and bone flap. Each case had on uneventful postoperative course. In conclusion, the complete removal of the ePTFE sheet and bone flap is mandatory for postcraniotomy infection in such cases. And dural defects after removal of the ePTFE sheet do not need to be replaced with any dural substitute as long as cranioplasty is not performed simultaneously. Staged cranioplasty in cases without dural replacement is not so difficult because the membrane formed beneath the ePTFE sheet protects the brain just like replaced dura mater.

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Recent popularization of multidetector-row CT makes it possible to evaluate cerebral vessels anatomically and cerebral perfusion noninvasively. To evaluate the usefulness and limitations of 3-dimensional CT angiography (CTA) combined with CT perfusion (CTP) for the diagnosis and management of vasospasm, we examined 18 patients with ruptured aneurysmal subarachnoid hemorrhage. In a total of 5 cases, vasospasm was demonstrated angiographically on CTA findings as well as hypoperfusion state on CTP findings. Four of these with CTP-diagnosed decrease in cerebral blood volume (CBV) demonstrated the development of permanent cerebral infarction on the subsequent CT findings, whereas another case without CBV abnormality demonstrated reversible ischemia. Moreover, 1 case showed hypoperfusion on CTP but not vasospasm on CTA finding. This patient was diagnosed as having very mild vasospasm of middle cerebral artery. In conclusion, using CTA in combination with CTP methods was able to establish the diagnosis promptly and was very useful for the accurate detection of vasospasm after subarachnoid hemorrhage.

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Carotid artery stenting (CAS) has become a widely-used option to treat patients with carotid stenosis. Although technical improvements have led to a decrease in complications related to CAS, distal embolism continues to be a problem. To ensure the safety of CAS, the plaque characteristics must be clearly understood before commencing with the procedure. While ultrasonography (US) is a non-invasive, highly effective method for evaluating the plaque characteristics, interpretation of the results is subjective and the assessment of high-positioned plaques is difficult. We analyzed the suitability and efficacy of Virtual Histology IVUS (VH-IVUS) for the assessment of carotid stenosis. This method was used in 10 patients with CAS ; they underwent color-mapping for 4 types of plaque components, i.e. fibrous-, fibro-fatty-, and calcium components, and necrotic core. The results of VH-IVUS analysis showed that soft- and calcified plaques tended to contain a grater amount of debris. We suggest that the evaluation of plaques by VH-IVUS yields highly reproducible and objective results that can be used to determine the necessity of protective devices, and as an aid in the selection of stents and the setting of the inflation pressure at time of PTA in patients undergoing CAS.

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