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This article has been peer reviewed. It is the authors' final version prior to publication in Neurosurgery

Volume 73, Issue 5, November 2013, Pages 908-910.

The published version is available at DOI: 10.1227/NEU.0000000000000121.. Copyright © Lippincott, Williams and Wilkins


1. Significance/Context and Importance of the Study:

Idiopathic normal pressure hydrocephalus (INPH) was first defined by Hakim and colleagues in 19651, and its symptoms later classified by the clinical triad of gait dysfunction, urinary incontinence, and dementia. The exact pathophysiology of this disease is not well understood.2 Surgical options for the treatment of INPH are ventriculoperitoneal shunt (VPS) placement (most commonly with a programmable valve), and endoscopic third ventriculostomy (ETV). VPS is by far the most common method used to treat INPH worldwide. Debate exists as to the superiority between the two management options. Historically, VPS placement with a programmable valve has led to improved outcomes with INPH.3 More recent use of ETV has been reported in the form of retrospective data, demonstrating neurological improvement in up to 69% of patients.4 However, a cited limitation of this study is the less stringent diagnostic criteria that fails to discriminate secondary NPH from INPH. This is important because of the higher success rates of treatment in secondary NPH.2 This study by Pinto et al should be commended for its attempt to compare ETV to VPS with a nonprogrammable valve for patients with the diagnosis of INPH prospectively. Given that the natural history of VPS carries a significant rate of shunt revision, there have been no prior attempts to provide level I evidence demonstrating equivalence or superiority of ETV to VPS placement.

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