ORIGINAL PAPER Modified bilateral subtemporal decompression for resistant slit ventricle syndrome Jonathan Roth & Naresh Biyani & Suhas Udayakumaran & Xiao Xiao & Orna Friedman & Liana Beni-Adani & Shlomi Constantini Received: 4 May 2010 / Accepted: 28 June 2010 # Springer-Verlag 2010 Abstract Purpose Slit ventricle syndrome (SVS) remains a major problem for early shunted children. Several conservative and surgical treatment paradigms have been suggested; however, there is no consensus on the optimal surgical treatment. We present our experience using bilateral subtemporal decompressions with dura and arachnoid opening for the treatment of a subgroup of children with severe and resistant SVS. Methods Fifteen children with severe and resistant SVS underwent a modified bilateral subtemporal craniectomy, with dura and arachnoid opening. Their clinical and radiological data were retrospectively reviewed. Results Seven (46.6%) patients had a complete recovery from their symptoms with a follow-up of 5.9±2.6 years.The remaining eight (53.3%), underwent additional surgeries. Four (26.6%), had a single proximal shunt revision after dilatation of their ventricles. Following these procedures these four children are well and stable with a follow-up of 1.8±2 years. The other four had further cranial vault expansion, one of which was followed by a proximal shunt revision. Thus, 11 of these 15 patients (73.4%) had a very good outcome, attributable to this technique, with a mean follow-up of 4.5±3 years. Conclusions Modified bilateral subtemporal decompression with dura and arachnoid opening yields a high cure rate for severe and resistant slit ventricle syndrome. Proximal shunt revision may be safely performed in a subset of patients that dilate their ventricles following the procedure. Further cranial expansion may be reserved for children with recurrent SVS symptoms who do not respond to STD and remain with very small ventricles. Keywords Subtemporal decompression . Slit ventricle syndrome . Hydrocephalus . Shunt revision . Intra-cranial pressure Introduction Slit ventricle syndrome (SVS) occurs in 1–5% of shunted children, more commonly among children shunted at a very young age [2, 5, 9, 19, 21, 27]. The chronic course of intermittent headaches, vomiting, and somnolence, pose a great burden on the children, their family, and their treating physicians. These children frequently present to the emergency room with severe symptoms, undergo repeated imaging, including CT and MRI scans, as well as shunt series. However, these tests usually demonstrate small ventricles and thus are often interpreted as normal. Many of these children also undergo frequent shunt revisions. Children may be symptom free for long periods, interrupted by attacks of severe symptoms, for various durations, sometimes associated with a childhood viral disease. Even when the diagnosis of SVS is made, the preferred treatment is controversial. Short courses of steroids and acetazolamide [11], as well as lumbar punctures, may relieve the symptoms for a while; however, symptoms often recur. Several surgical procedures have been described treating SVS, including shunt revisions, lumboperitoneal shunts, cranial expansion (CE), and subtemporal decompression (STD). The variety of surgical options emerges from the not completely understood pathophysiology of SVS, and the complexity of this condition. J. Roth : N. Biyani : S. Udayakumaran : X. Xiao : O. Friedman : L. Beni-Adani : S. Constantini (*) Department of Pediatric Neurosurgery, Dana Children’ s Hospital, Tel Aviv Medical Center, Tel Aviv University, 6 Weizman Street, Tel Aviv 64239, Israel e-mail: sconsts@netvision.net.il Childs Nerv Syst DOI 10.1007/s00381-010-1220-0