J Neurosurg 145:1410–1416, 2026
In adults with a mass obstructing cerebrospinal fluid (CSF) flow, the site of obstruction helps determine what endoscopy can achieve. Fenestrating a cyst may reopen a ventricular passage, while a septostomy can connect isolated compartments so that one shunt catheter drains both. Hess and Ormond also identified a reason to reconsider an initially successful bypass: tumor progression or leptomeningeal spread can change the mechanism of hydrocephalus.
Study and key findings
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The authors reviewed 98 adults with obstructive hydrocephalus treated by one surgeon between 2014 and 2025. Initial management consisted of endoscopy in 77 patients, a combined endoscopic and shunt procedure in 14, and shunting alone in seven. Patients presenting with communicating hydrocephalus underwent primary shunting and were excluded from this analysis.
Among patients selected for primary endoscopy, all 13 with nonneoplastic cysts remained shunt free during follow-up, as did 16 of 17 with brain metastases. None of the latter had evidence of leptomeningeal disease. Shunt independence was less frequent with glioma (10 of 18) and CNS lymphoma (two of four). Of the 14 patients treated endoscopically to simplify a shunt system, one required revision.
Interpretation and limitations
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The precise overall success rate is uncertain. Table 3 lists 66 of 77 patients as shunt independent but also records 17 failures, and the article does not reconcile those counts. Referral patterns, anatomy-based selection, small pathology groups, and differences in survival further limit comparisons between procedures.
Clinical takeaway
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Identify the obstructed compartment and assess whether the proposed opening will restore a continuous CSF pathway. In this series, a narrow prepontine cistern limited the size of one third ventriculostomy, and five patients with glioma underwent primary shunting for trapped temporal horns. If symptoms recur after endoscopy, reassess both the opening and the underlying disease. Leptomeningeal spread, hemorrhage, or ventriculitis can add a communicating component that changes the choice of diversion.