Endoscopic third ventriculostomy versus shunt for pediatric hydrocephalus: a systematic literature review and meta-analysis



Optimized management of pediatric hydrocephalus remains the subject of debate. Ventriculoperitoneal shunt is largely considered the standard of care. However, the advancements and introduction of new cerebrospinal fluid (CSF) diversion approaches including the use of endoscopic third ventriculostomy (ETV) offer appealing alternatives that have been reported in numerous observational series.


To evaluate the comparative safety and efficacy of shunting and ETV in pediatric hydrocephalus cases.


This systematic literature review was performed according to the PRISMA guidelines. Eligible studies were identified through a search of PubMed (Medline) and Cochrane until October 2018. A random effects model meta-analysis was conducted and the I-square was used to assess heterogeneity. The ROBINS-1 tool and Cochrane tool were used to assess risk of bias in the observational and randomized studies, respectively.


Fourteen studies including 8419 patients were identified. Patients in the ETV group had a statistically significant lower risk of infection compared to shunt (OR: 0.19; 95% CI: 0.07–0.53; I2: 0%). All-cause mortality (OR: 0.77; 95% CI: 0.35–1.68; I2: 0%), post-operative CSF leak (OR: 1.53; 95% CI: 0.37–6.31; I2: 0%), and reoperation rates were similar between the two study groups (OR: 0.72; 95% CI: 0.39–1.32; I2: 93.5%). Subgroup analyses for re-operation demonstrated that ETV in Africa (OR: 0.13; 95% CI: 0.03–0.48; I2: 0%) and Europe (OR: 0.39; 95% CI: 0.30–0.52; I2:1.4%) was associated with significantly lower odds of re-operation compared to shunt, but not in USA/Canada (OR: 1.49; 95% CI: 0.85–2.63; I2:86.2%). Meta-regression analyses of age and duration of follow-up did not affect re-operation rates.


ETV was associated with a statistically significant lower risk of procedure-related infection compared to shunt. All-cause mortality, CSF leak, and re-operation rates were similar between the study groups. Subgroup analysis based on the geographic region showed that ETV is associated with statistically significant lower odds for re-operation in Europe and Africa, but not in USA/Canada. Future RCTs are needed to validate the results of this study and elucidate the cause of this heterogeneity.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7


  1. 1.

    Beuriat P-A, Puget S, Cinalli G, Blauwblomme T, Beccaria K, Zerah M, Sainte-Rose C (2017) Hydrocephalus treatment in children: long-term outcome in 975 consecutive patients. J Neurosurg Pediatr 20:10–18. https://doi.org/10.3171/2017.2.PEDS16491

    Article  PubMed  Google Scholar 

  2. 2.

    Pople IK (2002) Hydrocephalus and shunts: what the neurologist should know. J Neurol Neurosurg Psychiatry 73(Suppl 1):i17–i22

    PubMed  PubMed Central  Google Scholar 

  3. 3.

    Jernigan SC, Berry JG, Graham DA, Goumnerova L (2014) The comparative effectiveness of ventricular shunt placement versus endoscopic third ventriculostomy for initial treatment of hydrocephalus in infants. J Neurosurg Pediatr 13:295–300. https://doi.org/10.3171/2013.11.PEDS13138

    Article  PubMed  Google Scholar 

  4. 4.

    Uche EO, Onyia E, Mezue UC, Okorie E, Ozor II, Chikani MC (2013) Determinants and outcomes of ventriculoperitoneal shunt infections in Enugu, Nigeria. Pediatr Neurosurg 49:75–80. https://doi.org/10.1159/000357384

    Article  CAS  PubMed  Google Scholar 

  5. 5.

    Stein SC, Guo W (2008) Have we made progress in preventing shunt failure? A critical analysis. J Neurosurg Pediatr 1:40–47. https://doi.org/10.3171/PED-08/01/040

    Article  PubMed  Google Scholar 

  6. 6.

    Kulkarni AV, Riva-Cambrin J, Butler J, Browd SR, Drake JM, Holubkov R, Kestle JRW, Limbrick DD, Simon TD, Tamber MS, Wellons JC, Whitehead WE (2013) Outcomes of CSF shunting in children: comparison of hydrocephalus clinical research network cohort with historical controls: clinical article. J Neurosurg Pediatr 12:334–338. https://doi.org/10.3171/2013.7.PEDS12637

    Article  PubMed  Google Scholar 

  7. 7.

    Greitz D (2007) Paradigm shift in hydrocephalus research in legacy of Dandy’s pioneering work: rationale for third ventriculostomy in communicating hydrocephalus. Childs Nerv Syst 23:487–489. https://doi.org/10.1007/s00381-007-0303-z

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Koch-Wiewrodt D, Wagner W (2006) Success and failure of endoscopic third ventriculostomy in young infants: are there different age distributions? Childs Nerv Syst 22:1537–1541. https://doi.org/10.1007/s00381-006-0191-7

    Article  PubMed  Google Scholar 

  9. 9.

    Hopf NJ, Grunert P, Fries G, Resch KDM, Perneczky A (1999) Endoscopic third ventriculostomy: outcome analysis of 100 consecutive procedures. Neurosurgery 44:795–796

    Article  CAS  PubMed  Google Scholar 

  10. 10.

    Cinalli G, Salazar C, Mallucci C et al (1998) The role of endoscopic third ventriculostomy in the management of shunt malfunction. Neurosurgery 43:1323–1329

    CAS  PubMed  Google Scholar 

  11. 11.

    Warf BC (2005) Comparison of endoscopic third ventriculostomy alone and combined with choroid plexus cauterization in infants younger than 1 year of age: a prospective study in 550 African children. J Neurosurg 103:475–481. https://doi.org/10.3171/ped.2005.103.6.0475

    Article  PubMed  Google Scholar 

  12. 12.

    Warf BC, Tracy S, Mugamba J (2012) Long-term outcome for endoscopic third ventriculostomy alone or in combination with choroid plexus cauterization for congenital aqueductal stenosis in African infants. J Neurosurg Pediatr 10:108–111. https://doi.org/10.3171/2012.4.PEDS1253

    Article  PubMed  Google Scholar 

  13. 13.

    Pan I-W, Harris DA, Luerssen TG, Lam SK (2017) Comparative effectiveness of surgical treatments for pediatric hydrocephalus. Neurosurgery 0:1–8. https://doi.org/10.1093/neuros/nyx440

    Article  Google Scholar 

  14. 14.

    Kulkarni AV, Schiff SJ, Mbabazi-Kabachelor E, Mugamba J, Ssenyonga P, Donnelly R, Levenbach J, Monga V, Peterson M, MacDonald M, Cherukuri V, Warf BC (2017) Endoscopic treatment versus shunting for infant hydrocephalus in Uganda. N Engl J Med 377:2456–2464. https://doi.org/10.1056/NEJMoa1707568

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, Shekelle P, Stewart LA, the PRISMA-P Group (2015) Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ 349:g7647

    Article  Google Scholar 

  16. 16.

    Sterne JA, Hernan MA, Reeves BC et al (2016) ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 355:i4919

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Higgins JPT, Altman DG, Gøtzsche PC et al (2011) The Cochrane collaboration’s tool for assessing risk of bias in randomised trials. BMJ 343:d5928. https://doi.org/10.1136/bmj.d5928

  18. 18.

    Higgins JPT, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ 327:557–560. https://doi.org/10.1136/bmj.327.7414.557

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Cairo SB, Agyei J, Nyavandu K, Rothstein DH, Kalisya LM (2018) Neurosurgical management of hydrocephalus by a general surgeon in an extremely low resource setting: initial experience in north Kivu province of eastern Democratic Republic of Congo. Pediatr Surg Int 34:467–473. https://doi.org/10.1007/s00383-018-4238-0

    Article  PubMed  Google Scholar 

  20. 20.

    Uche EO, Okorie C, Iloabachie I, Amuta DS, Uche NJ (2018) Endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in non-communicating hydrocephalus (NCH): comparison of outcome profiles in Nigerian children. Childs Nerv Syst 34:1683–1689. https://doi.org/10.1007/s00381-018-3848-0

    Article  PubMed  Google Scholar 

  21. 21.

    Beuriat P-A, Szathmari A, Grassiot B, Plaisant F, Rousselle C, Mottolese C (2016) Role of endoscopic third Ventriculostomy in the Management of Myelomeningocele-Related Hydrocephalus: a retrospective study in a single French institution. World Neurosurg 87:484–493. https://doi.org/10.1016/j.wneu.2015.07.071

    Article  PubMed  Google Scholar 

  22. 22.

    Kulkarni AV (2016) International infant hydrocephalus study : initial results of a prospective , multicenter comparison of endoscopic third ventriculostomy ( ETV ) and shunt for infant hydrocephalus. Childs Nerv Syst 32:1039–1048. https://doi.org/10.1007/s00381-016-3095-1

    Article  PubMed  Google Scholar 

  23. 23.

    Paulsen AH, Due-tønnessen BJ, Lundar T, Lindegaard K (2016) Cerebrospinal fluid ( CSF ) shunting and ventriculocisternostomy ( ETV ) in 400 pediatric patients . Shifts in understanding , diagnostics , case-mix , and surgical management during half a century. Childs Nerv Syst 33:1–10. https://doi.org/10.1007/s00381-016-3281-1

    Article  Google Scholar 

  24. 24.

    El-Ghandour NMF (2011) Endoscopic third ventriculostomy versus ventriculoperitoneal shunt in the treatment of obstructive hydrocephalus due to posterior fossa tumors in children. Childs Nerv Syst 27:117–126. https://doi.org/10.1007/s00381-010-1263-2

    Article  PubMed  Google Scholar 

  25. 25.

    Appelgren T, Zetterstrand S, Elfversson J, Nilsson D (2010) Long-term outcome after treatment of hydrocephalus in children. Pediatr Neurosurg 46:221–226. https://doi.org/10.1159/000319365

    Article  PubMed  Google Scholar 

  26. 26.

    de Ribaupierre S, Rilliet B, Vernet O, Regli L, Villemure JG (2007) Third ventriculostomy vs ventriculoperitoneal shunt in pediatric obstructive hydrocephalus: results from a Swiss series and literature review. Childs Nerv Syst 23:527–533. https://doi.org/10.1007/s00381-006-0283-4

    Article  PubMed  Google Scholar 

  27. 27.

    Garton HJL, Kestle JRW, Cochrane DD, Steinbok P (2002) A cost-effectiveness analysis of endoscopic third ventriculostomy. Neurosurgery 51:68–69

    Article  Google Scholar 

  28. 28.

    Tuli S, Alshail E, Drake J (1999) Third ventriculostomy versus cerebrospinal fluid shunt as a first procedure in pediatric hydrocephalus. Pediatr Neurosurg 30:11–15. https://doi.org/10.1159/000028753

    Article  CAS  PubMed  Google Scholar 

  29. 29.

    Pan I-W, Harris DA, Luerssen TG, Lam SK (2018) Comparative effectiveness of surgical treatments for pediatric hydrocephalus. Neurosurgery 83:480–487. https://doi.org/10.1093/neuros/nyx440

    Article  PubMed  Google Scholar 

  30. 30.

    Kestle JRW, Holubkov R, Douglas Cochrane D, Kulkarni AV, Limbrick DD, Luerssen TG, Jerry Oakes W, Riva-Cambrin J, Rozzelle C, Simon TD, Walker ML, Wellons JC, Browd SR, Drake JM, Shannon CN, Tamber MS, Whitehead WE (2016) A new hydrocephalus clinical research network protocol to reduce cerebrospinal fluid shunt infection. J Neurosurg Pediatr 17:391–396. https://doi.org/10.3171/2015.8.PEDS15253

    Article  PubMed  Google Scholar 

  31. 31.

    Pham ACQ, Fan C, Owler BK (2013) Treating pediatric hydrocephalus in Australia: a 3-year hospital-based cost analysis and comparison with other studies. J Neurosurg Pediatr 11:398–401. https://doi.org/10.3171/2013.1.PEDS12233

    Article  PubMed  Google Scholar 

  32. 32.

    Li C, Gui S, Zhang Y (2017) Compare the safety and efficacy of endoscopic third ventriculostomy and ventriculoperitoneal shunt placement in infants and children with hydrocephalus: a systematic review and meta-analysis. Int J Neurosci:1–30. https://doi.org/10.1080/00207454.2017.1348352

  33. 33.

    Kulkarni AV, Riva-Cambrin J, Rozzelle CJ, Naftel RP, Alvey JS, Reeder RW, Holubkov R, Browd SR, Cochrane DD, Limbrick DD, Simon TD, Tamber M, Wellons JC, Whitehead WE, Kestle JRW (2018) Endoscopic third ventriculostomy and choroid plexus cauterization in infant hydrocephalus: a prospective study by the hydrocephalus clinical research network. J Neurosurg Pediatr 21:214–223. https://doi.org/10.3171/2017.8.PEDS17217

    Article  PubMed  Google Scholar 

  34. 34.

    PT Higgins J, Green S (2009) Cochrane handbook for systematic reviews of interventions version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from http://handbook.cochrane.org. Accessed 3/5/2019

Download references

Author information



Corresponding author

Correspondence to Pavlos Texakalidis.

Ethics declarations

Conflict of interest


Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Prior Publication or Presentation

No portion of this paper has been previously presented or published in any academic or clinical proceedings or journals.

Electronic supplementary material

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Texakalidis, P., Tora, M.S., Wetzel, J.S. et al. Endoscopic third ventriculostomy versus shunt for pediatric hydrocephalus: a systematic literature review and meta-analysis. Childs Nerv Syst 35, 1283–1293 (2019). https://doi.org/10.1007/s00381-019-04203-2

Download citation


  • Endoscopic third ventriculostomy
  • Choroid plexus cauterization
  • Shunt
  • Shunting
  • Hydrocephalus