A Paradigm Shift in Hydrocephalus Management: The Promise of Endovascular Cerebrospinal Fluid Diversion

Normal pressure hydrocephalus (NPH) predominantly affects the elderly and is the most common form of adult-onset hydrocephalus. Clinically, it is characterized by Hakim’s triad—gait disturbance, dementia, and urinary incontinence—and is marked by abnormal cerebrospinal fluid accumulation without increased intracranial pressure. Although the exact pathophysiology is not fully understood, proposed mechanisms include glymphatic dysfunction, blood–brain barrier disruption, and hypoperfusion. In carefully selected patients, the standard treatment, ventriculoperitoneal shunting, can provide significant improvement in gait stability and urinary incontinence, and to a lesser extent, cognitive decline. However, ventriculoperitoneal shunting carries substantial risks, including infection, need for revision, and over-drainage, highlighting the urgent need for safer, more effective treatment options. CereVasc’s eShunt System is a promising, minimally invasive alternative. This 3-cm biomimetic device is deployed via a percutaneous transvenous approach in the inferior petrosal sinus. It is deployed across the wall of the venous sinus and dura mater and thereby mimics the function of an arachnoid granulation by passively diverting cerebrospinal fluid from the cerebellopontine angle cistern into the internal jugular vein. It is hoped that this minimally invasive approach will reduce the risks associated with conventional shunting. This brief opinion piece reviews NPH, the challenges of current treatments, and the potential of the eShunt System. Preliminary data from ongoing clinical trials suggest that the eShunt System may represent a minimally invasive treatment option for patients with NPH and other forms of communicating hydrocephalus. Furthermore, this technology may serve as a platform for advanced central nervous system drug delivery, broadening its impact on neurointerventional therapies.