Objective <p>Cerebrospinal fluid (CSF)-overdrainage (OD) may occur in short- or long-time shunt treatment with a variety of clinical symptoms or radiographic findings ranging from mild postural headaches to chronic hygroma or even acute subdural hematoma. Shunt-valve pressure level adjustability and prevention of the siphoning effect with anti-siphon devices and gravitational units have fundamental influence on the current standards of modern CSF-valve technology. However, OD may also occur despite the upfront use of those prophylactic technologies. The aim of this study is to determine incidence and clinical management of OD in pediatric hydrocephalus patients treated with modern gravitational valve shunts.</p> Methods <p>Using our institutional pediatric Hydrocephalus and Shunt Registry providing more than 700 individual shunt histories of varying hydrocephalus etiology, we analyzed the clinical course of all patients who were equipped with gravitational valves right from the start. Initial valve-type and pressure level settings as well as all subsequent pressure level adjustments or surgical valve-type alterations were analyzed corresponding to clinical and neuroimaging findings. The inclusion criteria were complete institutional ventricular CSF-shunt history and follow-up with initial insertion of a gravitational shunt valve. Time-to-event analyses used time from primary VP shunt implantation to first OD event; patients without OD were censored at last follow-up.</p> Results <p>Two hundred twenty-three patients met the inclusion criteria with a mean follow-up of 5.6 ± 2.1 years. Patients were initially equipped with the M.blue valve in 40 patients (18%) or the miniNAV/proSA valve in 144 patients (65%). During the entire follow-up, 78 patients (35%) developed clinical and/or radiographic signs of OD, which were effectively manageable by pressure level adjustments alone in 81% and surgical intervention in 19% of the cases. The frequency of valve adjustments averaged 1.7 per patient. The mean initial pressure settings were 5.17 cmH₂O for differential pressure valve (DPV), 19.54 cmH₂O for gravitational unit (GAV), and 24.71 cmH₂O for upright pressure. At the latest follow-up, the mean pressure settings had increased to 5.44 cmH₂O for DPV, 21.69 cmH₂O for GAV, and 27.13 cmH₂O for upright pressure. In patients with the M.blue valve, 16 out of 40 (36%) experienced OD. For the miniNAV/proSA valve, 56 out of 144 patients (39%) showed signs of OD. In comparison, the proGAV valve had the lowest OD occurrence, with only 6 out of 39 patients (15%) affected. Temporary shunt ligation was performed in 2 patients, while an additional subdural hematoma (SDH) or hygroma drainage was needed in another 2 patients.</p> Conclusion <p>Long-term follow-up monitoring of shunt-treated pediatric patients reveals a not negligible incidence of OD even though the shunt system is already equipped with a preventive gravitational unit. Pressure level adjustments can effectively counteract corresponding clinical symptoms and radiographic signs. The proGAV valve demonstrated significantly longer adjustment-free survival with lower rates of OD-related interventions, indicating a potential advantage in reducing long-term complications.</p>