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PubMed This is a summary of 16 peer-reviewed journal articles Updated
Neurosurgery · Aqueductal Stenosis

Treating the Blockage: ETV vs. Shunts

At a Glance

Endoscopic Third Ventriculostomy (ETV) is the gold standard surgical treatment for aqueductal stenosis, creating a natural fluid bypass with a 91% success rate. VP shunts are an effective backup option, but they carry lifelong risks of hardware failure, infection, or overdrainage.

When it comes to treating Aqueductal Stenosis, the medical community has a clear favorite. Because the condition is a physical blockage in an otherwise healthy brain, it is the “ideal” case for a procedure that avoids permanent mechanical implants.

The goal of treatment is twofold: relieve the pressure on the brain and, whenever possible, allow the body to manage its own fluid flow naturally [1][2].

Endoscopic Third Ventriculostomy (ETV): The “Gold Standard”

An Endoscopic Third Ventriculostomy (ETV) is a surgical procedure that creates a “natural bypass.” Instead of placing a tube to drain fluid, a neurosurgeon uses a tiny camera (endoscope) to make a small opening in the floor of the third ventricle. This allows the trapped fluid to flow out and be absorbed by the body, effectively bypassing the blockage in the aqueduct [1][3].

  • Success Rates: For patients with aqueductal stenosis, ETV is highly successful, with about 91% of patients remaining shunt-free for years after the procedure [4][5].
  • The Advantage: Unlike a shunt, an ETV has no mechanical parts that can break, clog, or become infected over time [6][2].
  • Surgical Risks: While it lacks mechanical parts, an ETV is still a major brain surgery. Risks include bleeding (hemorrhage), infection (meningitis), or accidental injury to nearby critical structures like the hypothalamus or pituitary gland, which regulate hormones and bodily functions [1][7].

Understanding the ETV Success Score (ETVSS)

Not every patient has the same chance of success with an ETV. Doctors use a tool called the ETV Success Score (ETVSS) to predict how likely a patient is to stay shunt-free. This score is based on three factors:

  1. Age: Older children and adults generally have higher success rates [8].
  2. The Cause: Aqueductal stenosis receives the highest points on this scale because it is a “pure” obstruction [8][5].
  3. Prior Shunt: Patients who have never had a shunt before often have a better chance of success [8][9].

Special Considerations for Infants: ETV + CPC

In babies under the age of one, the brain’s ability to absorb fluid is still developing, which can make a standard ETV less likely to work. To improve the odds, surgeons may combine ETV with Choroid Plexus Cauterization (CPC) [10][11].

In this “hybrid” procedure, the surgeon uses a tool to gently reduce the tissue (choroid plexus) that produces the brain’s fluid. By both creating a bypass (ETV) and “turning down the faucet” (CPC), many infants can avoid the need for a lifelong shunt [12][13].

The Alternative: Ventriculoperitoneal (VP) Shunts

A VP Shunt is a mechanical tube that carries fluid from the brain to the abdomen. While it is not the “first choice” for many AS patients today, it remains a vital backup plan [2][14].

  • When it is used: If a patient’s anatomy isn’t right for an ETV, or if an ETV has already failed [2].
  • The Trade-off: Shunts are very effective at reducing the size of enlarged ventricles, but they require lifelong maintenance. Most shunts will fail or require a “revision” (a follow-up surgery) at least once in a patient’s life [15][16].
  • Overdrainage Risk: A unique risk to shunts is overdrainage, which occurs when the shunt pulls too much fluid out too quickly. This can lead to severe headaches, a condition called “slit ventricle syndrome,” or even subdural hematomas (bleeding between the brain and skull) [15][2].
Feature ETV (Bypass) VP Shunt (Pipe)
Mechanical Parts None Yes (tube and valve)
Infection Risk Low over time Higher (lifelong)
Overdrainage Risk Very Rare Significant
Failure Type Often sudden (requires monitoring) Often gradual or acute
Ventricle Size May stay large but stable Usually shrinks significantly

What to Expect: Surgery and Recovery

If you or your child are preparing for surgery, having an idea of the timeline can ease anxiety:

  1. Preparation: Some hair may be shaved, typically a small strip or patch rather than the entire head, though this depends on the surgeon.
  2. Hospital Stay: Expect to spend 1 to 2 nights in the Intensive Care Unit (ICU) for close neurologic monitoring, followed by 1 to 3 days in a regular room.
  3. Recovery at Home: Most adults require 2 to 6 weeks off from work. Activities like heavy lifting or straining are restricted during this time to allow the brain and incisions to heal.

You can learn more about picking the right surgeon in Building Your Care Team and what happens long-term in Life After Surgery.

Common questions in this guide

What is the ETV Success Score (ETVSS)?
The ETV Success Score is a tool doctors use to predict how likely a patient is to stay shunt-free after an ETV procedure. It evaluates three main factors: the patient's age, the underlying cause of the fluid buildup, and whether they have had a prior shunt.
Why is CPC added to ETV surgery for infants?
In babies under one year old, the brain's ability to absorb fluid is still developing, which can make a standard ETV less successful. Surgeons add Choroid Plexus Cauterization (CPC) to reduce the tissue that produces brain fluid, improving the infant's chances of avoiding a lifelong shunt.
What are the risks of a VP shunt compared to an ETV?
VP shunts carry a lifelong risk of mechanical failure, infection, and overdrainage, which can cause severe headaches. While ETV avoids permanent mechanical parts, it is a major brain surgery that carries immediate risks such as bleeding, infection, or injury to nearby brain structures.
If I currently have a shunt, can I convert to an ETV?
Some patients with an existing shunt may be candidates to convert to an ETV to safely remove the mechanical device. Your neurosurgeon will evaluate your specific anatomy and prior shunt history to determine if this is a viable option for you.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.What is my (or my child's) ETV Success Score (ETVSS), and what does it say about our chances of staying shunt-free?
  2. 2.If we are treating an infant, do you perform 'Choroid Plexus Cauterization' (CPC) along with the ETV?
  3. 3.Based on my anatomy, is there anything (like thick membranes or blood vessels) that makes an ETV more technically difficult?
  4. 4.If the ETV fails, how quickly would symptoms return, and what is the emergency plan for a 'sudden closure'?
  5. 5.How do the long-term complication rates for a shunt in my specific case compare to the risks of a repeat ETV?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (16)
  1. 1

    Success Rate of Endoscopic Third Ventriculostomy in Children Younger Than 1 Year With Idiopathic Congenital Aqueductal Stenosis and Long-term Follow-up.

    Krejcí T, Kubina L, Krejcí O, et al.

    Journal of child neurology 2025; (40(2)):77-82 doi:10.1177/08830738241282356.

    PMID: 39878077
  2. 2

    Neuroendoscopic Diagnosis and Treatment of Adolescent-Onset Aqueductal Stenosis: A Report of Two Cases Demonstrating the Utility of Endoscopic Third Ventriculostomy.

    Sakakibara Y, Yamamoto M, Watanabe T, et al.

    Cureus 2025; (17(11)):e96666 doi:10.7759/cureus.96666.

    PMID: 41404208
  3. 3

    Successful endoscopic third ventriculostomy in children depends on age and etiology of hydrocephalus: outcome analysis in 51 pediatric patients.

    Duru S, Peiro JL, Oria M, et al.

    Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2018; (34(8)):1521-1528 doi:10.1007/s00381-018-3811-0.

    PMID: 29696356
  4. 4

    Long-Term Success of Endoscopic Third Ventriculostomy in the Pediatric Population with Aqueductal Stenosis.

    García-Milán V, Moreno-Madueño G, Urreta Juárez G, et al.

    World neurosurgery 2024; (189()):e364-e369 doi:10.1016/j.wneu.2024.06.056.

    PMID: 38901481
  5. 5

    Prognostic factors for endoscopic third ventriculostomy success in hydrocephalus with myelomeningocele.

    Macedo FAMC, Giannetti AV, Vandi HHS

    Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2024; (40(11)):3615-3620 doi:10.1007/s00381-024-06542-1.

    PMID: 39031215
  6. 6

    Surgical Outcome of CSF Drainage in Paediatric Obstructive Hydrocephalus.

    Das S, Rashid MM, Khan SI, et al.

    Mymensingh medical journal : MMJ 2021; (30(4)):1146-1153.

    PMID: 34605489
  7. 7

    Lower rates of symptom recurrence and surgical revision after primary compared with secondary endoscopic third ventriculostomy for obstructive hydrocephalus secondary to aqueductal stenosis in adults.

    Sankey EW, Goodwin CR, Jusué-Torres I, et al.

    Journal of neurosurgery 2016; (124(5)):1413-20 doi:10.3171/2015.4.JNS15129.

    PMID: 26517771
  8. 8

    External validation of the ETV success score in 313 pediatric patients: a Brazilian single-center study.

    Furtado LMF, da Costa Val Filho JA, Dos Santos Júnior EC

    Neurosurgical review 2021; (44(5)):2727-2734 doi:10.1007/s10143-020-01461-6.

    PMID: 33389340
  9. 9

    Predicting success of endoscopic third ventriculostomy: validation of the ETV Success Score in a mixed population of adult and pediatric patients.

    Labidi M, Lavoie P, Lapointe G, et al.

    Journal of neurosurgery 2015; (123(6)):1447-55 doi:10.3171/2014.12.JNS141240.

    PMID: 26207604
  10. 10

    Endoscopic third ventriculostomy and choroid plexus cauterization (ETV/CPC) for hydrocephalus of infancy: a technical review.

    Coulter IC, Dewan MC, Tailor J, et al.

    Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2021; (37(11)):3509-3519 doi:10.1007/s00381-021-05209-5.

    PMID: 33991213
  11. 11

    Impact of choroid plexus coagulation on the success of endoscopic third ventriculostomy in children with hydrocephalus: a single-center retrospective observational cohort study.

    da Cunha AHGB, Valença MM, Guerra PLN, da Silva ICS

    Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2025; (41(1)):108 doi:10.1007/s00381-025-06755-y.

    PMID: 39920432
  12. 12

    Treatment failure after endoscopic third ventriculostomy with choroid plexus cauterization, endoscopic third ventriculostomy alone, and ventriculoperitoneal shunt in congenital hydrocephalus: a network and time-to-event meta-analysis.

    Darko K, Kumar NM, Ferguson R, et al.

    Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2026; (42(1)):68 doi:10.1007/s00381-026-07165-4.

    PMID: 41670774
  13. 13

    Short-term outcomes of endoscopic third ventriculostomy and choroid plexus cauterization in children with hydrocephalus at Arusha Lutheran Medical Centre in northern Tanzania: a retrospective study.

    Mulla E, Rafka HE, Elahi C, et al.

    Journal of neurosurgery. Pediatrics 2025; (36(5)):563-569 doi:10.3171/2025.4.PEDS24549.

    PMID: 40815861
  14. 14

    International Infant Hydrocephalus Study (IIHS): 5-year health outcome results of a prospective, multicenter comparison of endoscopic third ventriculostomy (ETV) and shunt for infant hydrocephalus.

    Kulkarni AV, Sgouros S, Leitner Y, et al.

    Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2018; (34(12)):2391-2397 doi:10.1007/s00381-018-3896-5.

    PMID: 29987375
  15. 15

    Endoscopic third ventriculostomy (ETV) or ventriculoperitoneal shunt (VPS) for paediatric hydrocephalus due to primary aqueductal stenosis.

    Konar S, Singha S, Shukla D, et al.

    Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2024; (40(3)):685-693 doi:10.1007/s00381-023-06210-w.

    PMID: 37966498
  16. 16

    Shunt independence in paediatric hydrocephalus: our 16-year experience and review.

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    PMID: 31250092

This page provides educational information on surgical treatments for aqueductal stenosis, including ETV and VP shunts. It does not replace professional medical advice, diagnosis, or treatment planning from a qualified neurosurgeon.

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