Unlike conventional differential pressure shunts, gravitational shunts can be used in the treatment of high-risk patients with longstanding overt ventriculomegaly in adults. Significant risk of overdrainage can be avoided. Gravitational shunts offer a viable alternative to endoscopic third ventriculostomy, provided the choice and adjustment of the shunt opening pressure is based on a correct assessment of the hydrostatic pressure to be compensated for.