Objective: To analyze the Barrow Neurological Institute (BNI) grading scale, a quantitative scale measuring maximal subarachnoid hemorrhage thickness on axial computed tomography, on delayed cerebral ischemia (DCI) and outcome (modified Rankin scale; mRS) at discharge and 1-year follow-up (1FU) in patients with aneurysmal subarachnoid hemorrhage (aSAH) from a nationwide SAH registry. Methods All patient data was obtained from the Swiss nationwide multicentre registry database of aSAH (Swiss SOS). In 1321 patients demographic data, BNI scale, DCI and mRS up to the 1FU were available for descriptive and univariate statistics. Outcome was dichotomized in favorable (mRS 0-2) and unfavorable (mRS 3-6). Odds ratios (OR) for DCI of Fisher 3 patients (n=1115, 84%) compared to a control cohort of Fisher grade 1,2 and 4 patients (n=206, 16%) were calculated for each BNI grade separately. Results Overall, 409 patients (31 %) developed DCI with a high DCI rate in the Fisher 3 cohort (34%). For what concerns the BNI scale, DCI rates went up progressively from 26% (BNI 2) to 38% (BNI 5

BACKGROUND Giant thoracic disc herniation (gTDH) is a rare condition. It is defined by a herniation that occupies at least 40% of the thoracic spinal canal and is usually calcified. Several surgical techniques have been described to date but this surgery remains a technically difficult procedure. OBJECTIVE To report the long-term outcome of 53 patients with myelopathy due to gTDH who were operated on by a thoracoscopic approach. The technical details of the preoperative assessment and the surgical procedure are presented. METHOD We present a retrospective study of a database of 53 patients operated for symptomatic gTDH by a thoracoscopic approach. The following clinical parameters were assessed initially and used during follow-up: Frankel grade and JOA score adapted to the thoracic spine (mJOA), pain in the lower limbs and limitation of the walking perimeter to less than 500 meters. The quality of spinal cord decompression was assessed postoperatively by magnet resonance imaging (MRI). RESULTS The mean follow-up was 78.1 mo (SD 49.4). At the last follow-up visit, clinical examination showed a mean improvement of 0.91 Frankel grade (P < 0.001) and 2.56 mJOA score respectively (P < 0.001). Lower limb pain and walking perimeter were also improved. Postoperative MRI revealed that the resection was complete in 35 cases, subtotal in 13 cases, and incomplete in 5 cases. CONCLUSION gTDH is a condition that often evolves favorably after surgery. The thoracoscopic approach is a feasible alternative technique.

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BACKGROUND: Sophysa SM8 is widely used by neurosurgeons in France. Published studies report shunt malfunction rates in adults between 18% and 29%. However, these studies included multiple valve types and thus entailed a serious confounding factor. OBJECTIVE: To ascertain the incidence the Sophysa SM8 cerebrospinal fluid (CSF) shunt malfunctions in adults. METHODS: We present a retrospective series of adult patients who underwent CSF shunt placement between 2000 and 2013 with Sophysa SM8. RESULTS: In total, 599 patients (329 males and 270 females) were included. The mean age at surgery was 64.15 years (19-90) (SD 16.17; median 68.0). The causes of hydrocephalus were normal pressure hydrocephalus (49%), traumatic hemorrhages (26.5%), tumors (15.7%), cerebral aqueduct stenoses (3%), and arachnoid cysts (2%). The mean follow-up was 3.9 years (0-16) (SD 4.10; median 3 years). The rate of complications was 22.04% (132 of 599). Most frequent causes of complications were disconnection (25%), migration (12.9%), overdrainage (9.1%), and proximal obstruction (6.8%). In 17 cases (12.9%), no failure was diagnosed during revision. Seven infections (5.3%) were reported. The mean delay for the first revision was 1.70 years (0-13.93) (SD 2.67, median 0.35). The risk of shunt failure was 36% at 10 years. Seventeen percent of revisions occurred during the first year after shunt placement. CONCLUSION: Disconnections are a very frequent complication of Sophysa SM8 valve. They are related to the 2-connector system of this valve. Based on these results, we recommend using 1-piece valves.

To the Editor:Recently, we released one of the largest retrospective series studying the ball in cone mechanism of Sophysa in its 2 connectors version (599 implanted patients). 1 We found a global failure rate of 21.9% (131/599). An additional level of reading of the results should be provided. If we analyze the mechanical dysfunction etiologies not of the entire shunt but only of the device, it seems that the intrinsic complication rate of the mechanism of regulation of the opening pressure Sophysa is 3.5% as represented by proximal obstructions (9/599) and over drainages (12/599). Complications related to the double connector with a risk of disconnection are 5.3% (32/599). The 24.4% disconnection rate represents the disconnection rate in all complications (32/131). It therefore seems appropriate to recommend a 1-piece shunt for a primary implantation of Sophysa to reduce the risk of system disconnection by 5.3%. A comparison between 1-piece and 2-piece Sophysa device must be performed to calculate the additional risk associated with the use of this type of device. We also advise centers that treat hydrocephalus to check the risk of using dual connector systems, regardless of the brand of device.