From shunt dependency to shunt freedom: Endoscopic third ventriculostomy in ventriculoperitoneal shunt-dependent...

Hydrocephalus represents pathological dilatation of the ventricular system caused by impaired cerebrospinal fluid (CSF) circulation and absorption, resulting in increased intracranial pressure. Ventriculoperitoneal shunting (VPS) remains the standard treatment for communicating hydrocephalus; however, it is associated with significant long-term complications, including infection and mechanical failure. Endoscopic third ventriculostomy (ETV), traditionally indicated for obstructive hydrocephalus, has increasingly been explored in selected cases of complex and communicating hydrocephalus.

We report the case of a 28-year-old male with tetraventricular hydrocephalus secondary to childhood craniofacial trauma, initially managed with VPS placement in childhood. His clinical course was complicated by multiple shunt revisions due to recurrent infections and valve malfunction. During a prolonged hospital admission for shunt infection and distal peritonitis, repeated failures of temporary CSF diversion occurred despite external ventricular drainage and prolonged antimicrobial therapy. Brain magnetic resonance imaging with CSF flow studies demonstrated persistent tetraventricular hydrocephalus with preserved aqueductal patency, consistent with a communicating hydrocephalus pattern. Following confirmation of CSF sterility, ETV was performed as a definitive treatment strategy.

The procedure was completed without complications and resulted in progressive radiological resolution of hydrocephalus and sustained clinical improvement. The patient was discharged neurologically intact and free of permanent CSF diversion. This case highlights the potential role of ETV as a viable alternative to repeated shunt revisions in selected adult patients with communicating and tetraventricular hydrocephalus and underscores the need to reconsider traditional treatment paradigms in complex hydrocephalus management.