Current challenges in intrauterine management of obstructive fetal hydrocephalus and future directions

Aqueductal stenosis is a specific type of non- communicating hydrocephalus, which is characterized by narrowing or constriction of the cerebral aqueduct, also known as the aqueduct of Sylvius. Due to the blockage, the flow of cerebrospinal fluid (CSF) through the aqueduct becomes restricted or obstructed, leading to an abnormal accumulation of CSF within the ventricles and increased intracranial pressure. Progressive expansion of the ventricles leads to increasing cerebral mantle compression during fetal brain development, which can lead to irreversible damage with deleterious consequences. Early intervention could be crucial to mitigate the risk of subsequent cerebral injury. However, diagnostic challenges, unclear efficacy and frequent complications have hindered the integration of treatment for prenatal hydrocephalus into standard practice. Factors including improper patient selection, inadequate CSF diversion or fetal access techniques and suboptimal timing of intervention have been shown to impede success. To address these limitations and advance patient care, an evidence-based update of prenatal hydrocephalus interventions is warranted. This review aims to comprehensively explore the approaches to prenatal treatment of hydrocephalus from both a neurosurgical and fetal surgical perspective, integrating the latest advancements in prenatal diagnosis and fetal intervention. © 2025 International Society of Ultrasound in Obstetrics and Gynecology.