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Aqueductal stenosis is the primary cause of congenital and acquired hydrocephalus, which results from an obstruction in cerebrospinal fluid (CSF) flow through the cerebral aqueduct. The condition causes increasing intracranial pressure and progressive ventricular dilution that requires acute surgical intervention. Two of the primary treatment choices are ventriculoperitoneal (VP) shunting and endoscopic third ventriculostomy (ETV). Although VP shunting is still quite common, it has long-term side effects including shunt dependency, malfunction, and infection. By restoring CSF circulation, ETV presents a physiological substitute; yet, success rates depend on patient age, etiology, and anatomical factors. Rising approaches are ETV with choroid plexus cauterization, neuronavigation-assisted surgeries, and robotic-assisted neuroendoscopy, which is improving surgical results. Despite these advances, there nevertheless remain challenges in optimizing patient selection and minimizing postoperative complications. Emphasizing clinical decision-making and long-term management, this review offers an in-depth examination of the pathophysiology, diagnostic tools, and transforming surgical approaches for aqueductal stenosis.