Neurosurgery

Standard Treatment Options: Shunts and ETV

At a Glance

Hydrocephalus is treated by draining or bypassing excess brain fluid. VP shunts are commonly used for communicating hydrocephalus, while ETV is often considered for obstructive hydrocephalus; age, cause, prior surgery, and health help determine the safest option.

Deciding on a treatment for hydrocephalus involves choosing the best “fix” for the brain’s fluid plumbing. Because every patient’s brain is different, surgeons use a highly personalized approach based on the type of hydrocephalus, the person’s age, prior operations, and overall health. The goal is simple: to safely drain excess fluid and relieve the pressure that is interfering with brain function ^[1]^[2].

The Three Standard Procedures

There are three primary surgical options used today. Each has distinct advantages and is chosen based on the underlying cause of the fluid buildup.

VP Shunt (Ventriculoperitoneal Shunt): This is a common treatment. A thin, flexible tube is surgically placed in the brain’s ventricles. It runs under the skin to the abdomen, where the excess fluid is absorbed back into the body ^[3]. Shunts are a mainstay for communicating hydrocephalus and for many infants ^[4]. (Sometimes, based on the patient, shunts may be routed to the heart, pleural cavity, or from the lumbar spine).
ETV (Endoscopic Third Ventriculostomy): Instead of a tube, the surgeon uses a tiny camera to make a small hole in the floor of the third ventricle. This creates a “bypass” that allows fluid to escape and circulate naturally ^[5]. It is often used for obstructive (noncommunicating) hydrocephalus ^[6]^[7].
ETV with CPC (Choroid Plexus Cauterization): This is often used for selected infants. In addition to the ETV bypass, the surgeon uses a small electrical current to reduce the activity of the choroid plexus—the tissue that produces the fluid ^[8]^[9]. This “double-action” approach aims to reduce fluid production while improving drainage, potentially avoiding the need for a permanent shunt ^[10].

Choosing the Right Approach

Your medical team will look at several factors to decide which surgery offers the best chance of success. This is an individualized neurosurgical choice, not a strict rulebook.

The ETV Success Score (ETVSS)

To help predict if an ETV will work without a shunt in pediatric patients, doctors use a tool called the ETV Success Score ^[11]. It assigns a number based on:

Age: Older children typically have higher success rates ^[6].
Cause: Conditions like aqueductal stenosis (a narrow pathway) respond better than hydrocephalus caused by infection or bleeding ^[8].
Surgical History: Whether this is the first surgery or a revision ^[12].

An Illustrative Framework by Age

Infants (< 6 months): Infants often have a lower ETV success rate because their fluid-absorption system is immature. Shunts or ETV+CPC provide more reliable control depending on the specific cause ^[1]^[8]. Acute hydrocephalus may also require an emergency external ventricular drain (EVD).
Older Children and Adults: For those with a clear obstructive blockage, ETV is frequently considered because it avoids the lifelong risks of a “hardware” implant like a shunt ^[6]^[13].
Older Adults (iNPH): Most cases of iNPH are “communicating,” meaning there is no single blockage to bypass. A shunt is the standard way to manage this type ^[4].

Shunt Valves: Fixed vs. Adjustable

If a shunt is the best option, the surgeon must choose a “valve” that controls how much fluid is drained.

Fixed Valves: These are set to a specific pressure at the factory and cannot be changed after surgery.
Adjustable (Programmable) Valves: These allow a doctor to change the drainage pressure in the office using a special magnet—no surgery required ^[14]. This is helpful if a patient is draining too much (causing headaches) or too little (symptoms not improving) ^[15].
- MRI Caution: Some programmable valves can be “reset” by the strong magnets in an MRI machine ^[16]. If you have an adjustable valve, your setting must be checked and potentially restored by a specialist after every MRI ^[17]^[18].

Temporizing Measures for Fragile Infants

For very small or premature babies (especially those under 6 months or weighing less than 4 pounds), a permanent shunt may be too risky. In these cases, surgeons use “temporizing” devices like a ventricular reservoir or a subgaleal shunt ^[19]^[20]. These are small, temporary access points that allow doctors to manually remove fluid or let it drain under the skin until the baby is strong enough for a permanent procedure ^[21]^[22].

Managing Expectations and Risks

While these procedures are life-changing for many, they carry material surgical risks and are not a guaranteed “cure.”

Procedural Risks: Shunts can suffer from infection, mechanical obstruction, over-drainage (causing subdural bleeding), under-drainage, or abdominal complications ^[15]^[23]. ETV avoids hardware but the bypass hole can close over time, and rare complications include bleeding, seizures, or endocrine issues ^[24].
Shunt Dependency: While some patients eventually become shunt-independent, many shunts are for life and require monitoring for clogs or infections ^[1]. If an ETV fails, a shunt may still be required.
Success Rates: ETV success is highly dependent on the population, cause, and center. For example, it can be significantly lower in infants with post-hemorrhagic hydrocephalus compared to older children with aqueductal stenosis ^[25]^[6].
Non-Responders: Some patients, particularly older adults with advanced iNPH or patients with severe scarring from infection, may not see significant improvement even after a successful surgery because the underlying brain injury cannot be reversed ^[26]^[27]. Your doctor will use regular imaging and physical tests to track your progress and recovery.

Common questions in this guide

What is the difference between a VP shunt and ETV for hydrocephalus?

A VP shunt uses a tube to move extra fluid from the brain's ventricles to the abdomen, where the body absorbs it. ETV creates a small opening in the third ventricle so fluid can bypass a blockage and circulate. The choice depends on the type of hydrocephalus, age, previous surgery, and overall health.

How do doctors estimate whether ETV will work for a child?

For children, the ETV Success Score estimates the chance that ETV will control hydrocephalus without a shunt. It considers age, the cause of the fluid buildup, and whether the child has had earlier hydrocephalus surgery. It is an estimate, not a guarantee.

What should I know about a programmable shunt valve and MRI scans?

A programmable valve lets a clinician change the shunt's drainage pressure without another operation. The magnets used during some MRI scans can change the valve setting, so the setting should be checked and restored if needed after every MRI. Ask your specialist how your specific valve is managed.

What options are used for premature or very young babies with hydrocephalus?

Depending on the cause and the baby's size and health, treatment may include a shunt or ETV with choroid plexus cauterization. A temporary ventricular reservoir or subgaleal shunt may be used when a permanent shunt is too risky, allowing fluid to be managed until the baby is stronger. An external ventricular drain may be needed for acute hydrocephalus.

Do hydrocephalus shunts need to stay in for life?

Many shunts require lifelong monitoring for blockage, infection, or drainage problems, although some people eventually become independent of the shunt. A successful ETV can avoid a permanent shunt in some patients, but the opening can close and a shunt may still be needed. Follow-up visits and imaging help the care team assess treatment.

How will we know whether hydrocephalus treatment is working?

The care team may track symptoms, physical function, head circumference in infants, and brain imaging. A tense soft spot, changes in eating or sleeping, worsening headaches, or symptoms that do not improve can signal a problem and should be discussed promptly with the treating team.

Get notified when new evidence is published on Hydrocephalus.

We monitor PubMed for new peer-reviewed studies on this topic and email a short summary when something meaningful changes.

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This page is for informational purposes only and does not constitute medical advice. Your neurosurgical team should recommend the most appropriate procedure, valve, and follow-up plan for your situation.