Hybrid approach of combining valveless shunt systems with ETV for low-pressure hydrocephalus – a critical view regarding “Endoscopic Third Ventriculostomy plus Valveless Catheter in the Treatment of Low-Pressure Hydrocephalus” by the authors Villalonga JF

This letter to the editor critically evaluates the study by Villalonga et al. (2025) on treating low-pressure hydrocephalus (LPH) using combined endoscopic third ventriculostomy (ETV) and valveless shunts. We highlight several concerns: the hydrodynamic paradox of valveless overdrainage compromising long-term ETV patency, technical inconsistencies regarding stenting, and the questionable utility of ETV in communicating hydrocephalus. Furthermore, diagnosing LPH without external ventricular drainage (EVD) monitoring lacks accuracy, and essential details regarding prior shunt settings, tubing diameter, and long-term outcomes are missing. We advocate for rigorous EVD-based diagnosis and suggest adjustable low-setting valves over valveless systems until multicenter studies provide definitive evidence.

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