DOI: 10.33962/roneuro-2022-034 Delayed cerebrospinal fluid ascites following ventriculoperitoneal shunt. A case report with literature review Ahtesham Khizar, Soha Zahid Romanian Neurosurgery (2022) XXXVI (2): pp. 186-195 DOI: 10.33962/roneuro-2022-034 www.journals.lapub.co.uk/index.php/roneurosurgery Delayed cerebrospinal fluid ascites following ventriculoperitoneal shunt. A case report with literature review Ahtesham Khizar1, Soha Zahid2 1 Pakistan Institute of Medical Sciences, Islamabad, PAKISTAN 2 Jinnah Medical and Dental College, Karachi, PAKISTAN ABSTRACT Background: Cerebrospinal fluid (CSF) ascites is an abnormal accumulation of CSF within the peritoneal cavity caused by the peritoneum's inability to absorb the CSF, following a ventriculoperitoneal (VP) shunt surgery. Excessive CSF production (e.g, choroid plexus papilloma and choroid plexus villous hypertrophy), high CSF protein secondary to chronic infection (e.g., tuberculosis), and brain tumours (e.g, optic gliomas and craniopharyngiomas) have all been suggested as contributing factors to the formation of CSF ascites. Peritoneal inflammation as a result of several shunt revisions or some non-specific inflammatory reaction to shunt material has also been explored. Case Presentation: A 3-year-old girl with lumbar myelomeningocele and delayed CSF ascites following VP shunt is reported. Therapeutic paracentesis was employed to relieve abdominal distension, although recurring accumulation was common. The VP shunt was removed and instead of a Ventriculo-atrial shunt, she underwent Endoscopic Third Ventriculostomy (ETV). CSF ascites gradually disappeared after ETV over a two-week period. Conclusions: Abdominal paracentesis to relieve ascites and conversion of a Ventriculoperitoneal shunt to a Ventriculo-atrial shunt are commonly used to treat CSF ascites, however Endoscopic Third Ventriculostomy, where feasible, is another alternative treatment that can be performed to treat this condition. INTRODUCTION The most frequent procedure for hydrocephalus is a ventriculo- peritoneal (VP) shunt. They have been linked to a variety of issues, including dysfunction, infection, blockage, and migration. Rarely, the patient may develop increasing abdominal distention as a result of cerebrospinal fluid (CSF) accumulation. This is commonly referred to as a pseudocyst. The omentum produces a cyst at the tip of the shunt as a result of inflammation, resulting in a fluid-filled sac. Ascites is caused by a production-absorption mismatch or a non-absorbing peritoneum in very uncommon cases.[46] Ascites owing to hepatic, renal, or cardiac illness must be distinguished from CSF ascites, which is an abnormal buildup of CSF within the peritoneal cavity[38]. CSF ascites is a distinct condition in which there is an excessive Keywords hydrocephalus, cerebrospinal fluid ascites, endoscopic third ventriculostomy Corresponding author: Ahtesham Khizar Pakistan Institute of Medical Sciences, Islamabad, Pakistan arwain.6n2@gmail.com Copyright and usage. This is an Open Access article, distributed under the terms of the Creative Commons Attribution Non–Commercial No Derivatives License (https://creativecommons .org/licenses/by-nc-nd/4.0/) which permits non- commercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of the Romanian Society of Neurosurgery must be obtained for commercial re-use or in order to create a derivative work. ISSN online 2344-4959 © Romanian Society of Neurosurgery First published June 2022 by London Academic Publishing www.lapub.co.uk http://www.lapub.co.uk/ 187 Delayed cerebrospinal fluid ascites following ventriculoperitoneal shunt accumulation of CSF in the peritoneal cavity due to the peritoneum's inability to absorb it. This incapacity could be the result of a large amount of CSF being produced.[23] There have been several hypotheses on what factors may lead to the development of CSF ascites. Excessive CSF production (as in choroid plexus papilloma and choroid plexus villous hypertrophy), high CSF protein secondary to chronic infection (e.g. tuberculosis), and brain tumours (e.g, optic gliomas and craniopharyngiomas) have all been suggested as contributing factors to the formation of CSF ascites. Peritoneal inflammation as a result of several shunt revisions or some non-specific inflammatory reaction to shunt material has also been explored.[46] After ensuring that there is no infection, the VP shunt associated CSF ascites is treated by converting the shunt to a Ventriculoatrial shunt. Endoscopic Third Ventriculostomy (ETV) is another treatment option that can be done to treat this condition in selective cases. Figure 1. A: CSF swelling at reservoir site of VP shunt with distended abdomen and umbilical hernia due to CSF ascites, B: Abdominal incisional scar for VP shunt, C: Lumbar Myelomeningocele. Figure 2. A & B: X-ray shunt series showing VP shunt tubing marked by yellow arrows 188 Ahtesham Khizar, Soha Zahid Table 1. Detailed literature review of 77 previously reported cases of CSF ascites and their treatment. S.no. Author's Name Year reported No. of cases reported Gender/Age Cause/Type of Hydrocephalus Treatment for CSF ascites 1 R H Ames[1] 1967 1 M/2 years Congenital hydrocephalus Ventriculo-atrial shunt 2 D F Dean[2] 1972 1 M/1 year Aqueductal stenosis Ventriculo-atrial shunt 3 J D Rosenthal[3] 1974 1 F/3 years Suprasellar mass (Astrocytoma) Ventriculo-jugular shunt 4 Michael J. Weidmann[4] 1975 1 F/3 months Aqueductal stenosis Multiple Paracentesis followed by Ventriculo- atrial shunt 5 SW Parry[5] 1975 1 M/7 months Communicating hydrocephalus Ventriculo-atrial shunt 6 J Cummings[6] 1976 1 - Unknown - 7 R F Lees[7] 1978 2 - Unknown - 8 J M Noh[8] 1979 1 - Unknown - 9 S C Ohaegbulam[9] 1980 1 - 3rd ventricle compression by recurrent craniopharyngioma Spontaneous resolution following Paracentesis 10 A B Adegbite[10] 1982 1 F/11 years Recurrent craniopharyngioma VP shunt removal leading to resolution of ascites followed by new VP shunt 11 FP Agha[11] 1983 1 M/7 years Suprasellar astrocytoma Ventriculo-atrial shunt 12 R A Yount[12] 1984 4 1-F/6 years, 2-F/20 years, 3-M/4 years, 4-F/3 years 1-Communicating hydrocephalus, 2-Unknown, 3-Optic nerve glioma, 4-Optic nerve glioma 1-Ventriculo-cholecystic shunt, 2-Paracentesis and multiple taps of shunt reservoir, 3-Paracentesis and low- sodium diet, 4-Spontaneous resolution with fluid- restricted diet 13 Gairi Tahull JM[13] 1984 1 F/5 years Communicating hydrocephalus Ventriculo-atrial shunt 14 DS Rush[14] 1985 4 - - VP shunt revisions 189 Delayed cerebrospinal fluid ascites following ventriculoperitoneal shunt 15 D Madruga Acerete[15] 1988 1 F/12 years Dandy-Walker malformation - 16 G M Goodman[16] 1988 1 F/11 years Hydrocephalus following lumbar myelomeningocele repair Ventriculo-atrial shunt 17 S Niikawa[17] 1988 1 F/45 years Post-infectious obstructive hydrocephalus - 18 F Pérez Peña[18] 1990 1 M/17 years Malformation hydrocephalus - 19 A Suárez[19] 1993 1 M/22 years Craniopharyngioma Ventriculo-atrial shunt 20 A West[20] 1994 3 1-M/6 months, 2-M/6 years, 3-M/8 months Optic pathway gliomas Ventriculo-atrial shunts 21 A Shuper[21] 1997 1 F/4 years Optic chiasm glioma Ventriculo-atrial shunt 22 Michiko Yukinaka[22] 1998 1 F/23 years Congenital hydrocephalus with spina bifida Ventriculo-atrial shunt 23 B Chidambaram[23] 2000 2 1-F/3 months, 2-M/7 years 1-Congenital hydrocephalus, 2-Optic chiasm glioma 1-Ventriculo-atrial shunt, 2-Ventriculo-atrial shunt 24 Z Gil[24] 2001 4 1-M/9 years, 2-M/0.5 years, 3-M/0.5 years, 4-M/4 years 1-Optic pathway glioma, 2-Optic pathway glioma, 3-Optic pathway glioma, 4-Chiasmatic glioma Ventriculo-atrial shunts 25 BH Lee[25] 2001 1 M/68 years - VP shunt removal and antibiotics 26 GF Longstreth[26] 2001 1 F/28 years Communicating hydrocephalus Ventriculo-atrial shunt 27 GY Lee[27] 2002 1 F/33 years Congenital hydrocephalus Ventriculo-atrial shunt 28 Nayyar Yaqoob[28] 2003 1 M/17 years Tuberculous meningitis Anti-tuberculous therapy followed by Ventriculo-atrial shunt 29 Raj Kumar[29] 2003 4 1-M/9 years, 2-M/2 years, 1-Thalamic glioblastoma, 1-Paracentesis revealed peritoneal mets, 190 Ahtesham Khizar, Soha Zahid 3-M/4 years, 4-M/8 years 2-Choroid plexus papilloma of 3rd ventricle, 3-Tuberculous meningitis, 4- Craniopharyngioma 2-Ventriculo-atrial shunt followed by total excision of tumor, 3-Intraperitoneal cyst decompression, 4-Abdominal exploration and VP shunt revision 30 SJ Pawar[30] 2003 2 1-M/8 months, 2-M/2 years Choroid plexus papilloma of posterior 3rd ventricle 1-VP shunt revision, 2-Ventriculo-atrial shunt 31 Greg Olavarria[31] 2005 4 1-M/8 months, 2-M/8 months, 3-F/12 months, 4-F/12 months Optic chiasmal hypothalamic astrocytoma 1-Ventricular gallbladder shunt, 2-Ventricular gallbladder shunt, 3-Ventricular gallbladder shunt, 4-Ventricular gallbladder shunt converted to Ventriculo- atrial shunt 32 Michael L Diluna[32] 2006 1 M/4 years Arachnoid cyst Ventriculo-atrial shunt 33 Rajeev Kariyattil[33] 2007 5 3 males, 2 females Mean age: 3.7 years 1 Posterior fossa arachnoid cyst, 1 Hemorrhage, 1 Optic chiasm glioma, 1 Craniopharyngioma, 1 Meningomyelocele 4 Ventriculo-atrial shunts, 1 Spontaneous resolution after hypoproteinemia treatment 34 Paik I[34] 2010 1 F/21 years Myelomeningocele Ventriculo-atrial shunt 35 S Das[35] 2010 1 M/7 years Craniopharyngioma Ventriculo-atrial shunt 36 N Montano[36] 2010 1 F/51 years Obstructive hydrocephalus due to large Vestibular Schwannoma VP shunt removal, EVD placement, IV Teicoplanin and multiple ascitic fluid taps 37 WJ Wilma Houtman- van Duinen[37] 2011 1 F/29 years Congenital Cervical Meningocele Ventriculo-atrial shunt 38 MWANG’OMBE Nimrod Junius[38] 2012 1 M/7 years Aqueductal stenosis Ascites resolved within two weeks of endoscopic third ventriculostomy 39 Yin Yee Sharon Low[39] 2012 1 F/48 years Brain Mets from Breast Carcinoma with Obstructive hydrocephalus Peritoneal drain 191 Delayed cerebrospinal fluid ascites following ventriculoperitoneal shunt 40 Atakan Comba[40] 2013 1 F/6 years Myelomeningocele Ventriculo-atrial shunt 41 J Woodfield[41] 2013 1 F/1 year Craniopharyngioma Ventricular gallbladder shunt converted to Ventriculo-atrial shunt 42 Hira Jamal[42] 2016 1 F/37 years Idiopathic intracranial hypertension VP shunt removal, antibiotics and Ventriculo-atrial shunt 43 Maheen Siddiqi[43] 2017 1 F/16 years Congenital hydrocephalus Ventriculo-atrial shunt 44 D Sachan[44] 2017 1 M/5 years Choroid plexus papilloma Tumor resection and VP shunt removal 45 H Han[45] 2017 1 M/20 years Dandy-Walker Syndrome Ventriculo-atrial shunt 46 G. Musa[46] 2018 1 F/3 years Communicating hydrocephalus Ventriculo-atrial shunt 47 AA Khan[47] 2018 2 - - Endoscopic Third Ventriculostomy 48 Darrick K Li[48] 2019 1 F/26 years Loeys-Dietz syndrome and Congenital hydrocephalus Multiple therapeutic paracentesis followed by Peritoneovenous (Denver) shunt 49 Saud E. Suleiman[49] 2020 1 F/32 years Hydrocephalus due to brain malformation (corpus callosum agenesis) Multiple therapeutic paracentesis followed by Ventriculo-atrial shunt 50 George A.Alexiou[50] 2021 1 F/60 years Bilateral frontal meningiomas and Obstructive hydrocephalus Ventriculo-atrial shunt 51 M Mathew[51] 2022 1 F/7 years Craniopharyngioma Ventriculo-atrial shunt 52 N Mehta[52] 2022 1 M/29 years Communicating hydrocephalus Ventriculo-atrial shunt CASE PRESENTATION A 3-year-old girl appeared to us as an outpatient with complaints of frequent episodes of vomiting and reluctance to feed for three days, as well as abdominal distention for two weeks. She was born with a lumbar myelomeningocele and congenital hydrocephalus after a normal vaginal delivery at term. At the age of one month, she had a ventriculoperitoneal shunt placed, but she never had lumbar myelomeningocele repair surgery. She had been doing well since her ventriculoperitoneal shunt surgery until her current presentation. She was lethargic during the physical examination. There was a CSF surge at the VP shunt's reservoir site. Her belly was bloated, and she had an umbilical hernia and rectal prolapse, most likely as a result of excessive 192 Ahtesham Khizar, Soha Zahid intra-abdominal pressure caused by CSF ascites. (Figure 1; A,B,C). The VP shunt's reservoir was slow. We performed an X-ray shunt series, a Computed Tomography (CT) brain plain, and an abdominal ultrasound. Shunt tubing was found to be totally undamaged on X-ray (Figure 2; A&B). Ventriculomegaly was discovered on a CT scan. An abdominal ultrasound revealed complicated ascites. After a diagnostic paracentesis, the ascitic fluid was revealed to be normal. CSF ascites were confirmed through biochemical analysis. To reduce abdominal distension, therapeutic paracentesis was employed, although recurrent accumulation was common. Instead of a Ventriculo-atrial shunt, the VP shunt was removed, and she underwent Endoscopic Third Ventriculostomy. Following ETV, CSF ascites gradually disappeared over a two-week period. DISCUSSION Following the implantation of VP shunts for the treatment of hydrocephalus, a number of abdominal complications have been described. Perforation of the gut, gallbladder, vagina, umbilicus, and volvulus, as well as abdominal CSF encystation and CSF ascites, have all been documented.[5] Infections[12,26], malignancies, particularly choroid plexus papillomas and optico-chiasmatic gliomas[12,20,21,24,31], shunt- disseminated metastasis[39], and foreign body reactivity to the peritoneal catheter have been linked to CSF ascites.[23] High protein content of the CSF, particularly in optico-chiasmatic gliomas[10,20,31]; increased CSF production, as in choroid plexus hyperplasia and papillomas; tumor-secreted vascular permeability factors;[24] and persistent serosal inflammation are among the different causes reported.[26,33] To the best of our knowledge, Akdegbite et al. were the first to identify elevated CSF proteins as a probable cause of ascites.[10] As little is known about the aetiology of CSF ascites[4], various mechanisms have been proposed, including subclinical peritonitis, which obstructs lymphatic drainage[23], elevated CSF protein, which causes peritoneal malabsorption[10,24,28], and CSF overproduction exceeding absorptive capacity.[38] Multiple shunt revisions[2,22], an immunological reaction to vaccination[2], or shunt degradation[26] can all cause peritoneal irritation. Chronic illnesses such as tuberculosis[28] and brain tumours (e.g. optic gliomas and craniopharyngiomas)[24] have high CSF protein levels. Overproduction of the choroid plexus papillomas causes ascites.[30] A diagnosis of CSF ascites is strengthened by comparing the biochemistry of CSF shunt aspirate and ascitic fluid from paracentesis. CSF ascites resolve spontaneously when CSF flow is redirected using a Ventriculo-atrial shunt or ETV.[38] A previous shunt is linked to a higher rate of ETV failure.[47] In our situation, ETV was used, and symptoms were resolved within two weeks. A detailed literature review of 77 reported cases of CSF ascites until March 2022 is given in Table 1. Congenital hydrocephalus, obstructive hydrocephalus, choroid plexus papilloma, craniopharyngioma, and posterior fossa tumour were all common etiological causes. Revision of the VP shunt to a Ventricular-atrial shunt is the treatment of choice for CSF ascites, although revision in choroid plexus papilloma will only relieve ascites with the risk of congestive heart failure and bacteremia. The definitive cure is surgical excision of the papilloma.[44] Ascites developed and CSF protein levels increased in a craniopharyngioma instance that underwent VP shunt insertion due to hydrocephalus. CSF protein levels were reduced and ascites was alleviated after the recurring tumour was removed.[10] One patient with ascites and elevated protein levels was treated with a fluid-restricted diet by Yount et al.[12] According to the literature, the most common treatment overall for CSF ascites is abdominal paracentesis and conversion to a Ventriculo-atrial shunt. The time between VP shunt surgery and the onset of ascites might range from 1 day to 12 years.[23,38] It appeared in our patient 2.9 years after the VP shunt. In VP shunting, the peritoneal lining is particularly effective for quick absorption from the peritoneal cavity because it is made up of specialized mesothelial cells that promote rapid lymphatic drainage from the peritoneal cavity into the adjacent lymphatic lacunae.[39] In dehydrated children, the peritoneum can absorb up to 500 mL of normal saline per 24 hours, and following the osmotic absorption phase, the average fluid absorption rate is 33 mL/h.[51] CSF ascites is defined as an excessive buildup of CSF in the peritoneal cavity due to the peritoneum's failure to absorb the CSF.[23] According to literature study, this state of disequilibrium could be caused by primary peritoneal failure, increased CSF volume, increased CSF protein, infections (peritonitis), eosinophilic catheter rejection, immunological response to immunisation, or in 193 Delayed cerebrospinal fluid ascites following ventriculoperitoneal shunt certain cases, no clear cause. CSF ascites has been linked to tumours such optic gliomas and craniopharyngiomas, possibly due to elevated CSF proteins.[12, 23, 41] In addition to the probable unique proteins produced by optic gliomas, a disruption in the blood-brain barrier could allow tumour proteins to escape into the subarachnoid CSF, resulting in elevated protein levels and impaired CSF absorption through the arachnoid villi.[23] Patients with CSF ascites have an insidious onset, gradual abdominal distention, and no pain. Hepatic, renal, or cardiac dysfunction are not present. The duration between the shunt being placed and the onset of symptoms might range from days to years. To rule out other probable causes of ascites, a thorough study is required. In patients with a history of VP shunt surgery the likelihood of CSF ascites must be kept in mind, which can be validated by an ascitic fluid β2 transferrin assay. After making the diagnosis of CSF ascites, the treatment includes redirection of CSF flow, preferably Ventriculo-atrial shunt but Endoscopic Third Ventriculostomy is a viable approach in certain circumstances. CONCLUSIONS Patients with CSF ascites have an insidious onset, progressive and painless abdominal distention. The time between the shunt insertion and the onset of symptoms might range from days to years. An extensive workup is required to rule out other probable causes of ascites. After ensuring that there is no infection, the VP shunt linked CSF ascites is treated by converting the shunt to a Ventriculoatrial shunt. CSF ascites can be treated effectively by abdominal paracentesis and conversion of the VP shunt to a Ventriculo-atrial shunt, but Endoscopic Third Ventriculostomy is a viable approach in some selected cases. List of Abbreviations: CSF: Cerebrospinal fluid VP: Ventriculoperitoneal ETV: Endoscopic Third Ventriculostomy CT: Computed Tomography Acknowledgements: Not applicable. Funding: No funding was required for this work. Conflict of interest: The authors have no conflicts of interest. REFERENCES 1. Ames RH. Ventriculo-peritoneal shunts in the management of hydrocephalus. J Neurosurg. 1967;27(6):525-529. doi:10.3171/jns.1967.27.6.0525 2. Dean DF, Keller IB. Cerebrospinal fluid ascites: a complication of a ventriculoperitoneal shunt. Journal of Neurology, Neurosurgery & Psychiatry. 1972 Aug 1;35(4):474-6. 3. Rosenthal JD, Golden GT, Shaw CA, Jane JA. Intractable ascites: a complication of ventriculoperitoneal shunting with a silastic catheter. The American Journal of Surgery. 1974 May 1;127(5):613-4. 4. Weidmann MJ. Ascites from a ventriculoperitoneal shunt: Case report. Journal of Neurosurgery. 1975 Aug 1;43(2):233-5. 5. Parry SW, Schuhmacher JF, Llewellyn RC. Abdominal pseudocysts and ascites formation after ventriculoperitoneal shunt procedures: Report of four cases. Journal of Neurosurgery. 1975 Oct 1;43(4):476-80. 6. Cummings J, Sonntag KH, SCOTT RM. Ascites complicating ventriculo-peritoneal shunting in an adult. Surg Neurol. 1976;6(2):135-136. 7. Lees RF, Harrison RB, Shaffer Jr HA, Hamby LP. Cerebrospinal fluid ascites. Journal of the Canadian Association of Radiologists. 1978 Jun;29(2):132-3. 8. Noh JM, Reddy MG, Brodner RA. Cerebrospinal fluid ascites following ventriculoperitoneal shunt. Report of a case and review of the literature. Mt Sinai J Med. 1979;46(5):475-477. 9. Ohaegbulam SC. Cerebrospinal fluid ascites complicating a ventriculoperitoneal shunt. International surgery. 1980 Sep 1;65(5):455-7. 10. Adegbite AB, Khan M. Role of protein content in CSF ascites following ventriculoperitoneal shunting: Case report. Journal of neurosurgery. 1982 Sep 1;57(3):423-5. 11. Agha FP, Amendola MA, Shirazi KK, Amendola BE, Chandler WF. Unusual abdominal complications of ventriculo-peritoneal shunts. Radiology. 1983 Feb;146(2):323-6. 12. Yount RA, Glazier MC, Mealey J, Kalsbeck JE. Cerebrospinal fluid ascites complicating ventriculoperitoneal shunting: Report of four cases. Journal of neurosurgery. 1984 Jul 1;61(1):180-3. 13. JM GT, JM CC. Ventriculo-peritoneal shunt, hypovolemic shock and cerebrospinal fluid ascites. Anales Espanoles de Pediatria. 1984 Aug 1;21(2):147-52. 14. Rush DS, Walsh JW, Belin RP, Pulito AR. Ventricular sepsis and abdominally related complications in children with cerebrospinal fluid shunts. Surgery. 1985 Apr 1;97(4):420- 7. 15. Madruga Acerete D, Vascónez Muñoz F, Práxedes Alonso M, Cincuendez Morcuendez R, Salazar Rojas F, Taracena del Piñar B. Ascitis por líquido cefalorraquídeo como 194 Ahtesham Khizar, Soha Zahid complicación en derivación ventriculoperitoneal: aportación de un caso y revisión de la literatura [Ascites of the cerebrospinal fluid as a complication of a ventriculoperitoneal shunt: report of a case and a review of the literature]. An Esp Pediatr. 1988;28(6):565-568. 16. Goodman GM, Gourley GR. Ascites complicating ventriculoperitoneal shunts. Journal of pediatric gastroenterology and nutrition. 1988 Sep 1;7(5):780-2. 17. Niikawa S, Hara A, Nokura H, Uno T, Ohkuma A, Yamada H. Central nervous cryptococcosis giving rise to ascites after ventriculo-peritoneal shunting--a case report. No Shinkei geka. Neurological Surgery. 1988 Jun 1;16(7):881- 5. 18. Pérez Peña F, Aparicio Campillo G, López Asenjo JA, et al. Ascitis por acúmulo de líquido cefalorraquídeo [Ascites due to cerebrospinal fluid accumulation]. Rev Clin Esp. 1990;187(3):128-130. 19. Suarez A, Riestra S, Navascues CA, Sotorrio NG, Rodríguez M, Alonso JL, Pérez R, Rodrigo L. A ventriculoperitoneal shunt as a rare cause of ascites. Revista Espanola de Enfermedades Digestivas: Organo Oficial de la Sociedad Espanola de Patologia Digestiva. 1993 Apr 1;83(4):285-7. 20. West A, Berger MS, Geyer R. Childhood optic pathway tumors associated with ascites following ventriculoperitoneal shunt placement. Pediatric neurosurgery. 1994;21(4):254-9. 21. Shuper A, Horev G, Michovitz S, Korenreich L, Zaizov R, Cohen IJ. Optic chiasm glioma, electrolyte abnormalities, nonobstructive hydrocephalus and ascites. Medical and Pediatric Oncology: The Official Journal of SIOP— International Society of Pediatric Oncology (Societé Internationale d'Oncologie Pédiatrique. 1997 Jul;29(1):33- 5. 22. Yukinaka M, Nomura M, Mitani T, KONDO Y, TABATA T, NAKAYA Y, ITO S. Cerebrospinal ascites developed 3 years after ventriculoperitoneal shunting in a hydrocephalic patient. Internal medicine. 1998;37(7):638- 41. 23. Chidambaram B, Balasubramaniam V. CSF ascites: a rare complication of ventriculoperitoneal shunt surgery. Neurol India. 2000;48(4):378-380. 24. Gil Z, Beni-Adani L, Siomin V, Nagar H, Dvir R, Constantini S. Ascites following ventriculoperitoneal shunting in children with chiasmatic-hypothalamic glioma. Child's Nervous System. 2001 Jun;17(7):395-8. 25. Lee BH, Kang SD, Kim JM. CSF Ascites Complicating Ventriculoperitoneal Shunting-A Case Report. Journal of Korean Neurosurgical Society. 2001;30(11):1345-7. 26. Longstreth GF, Buckwalter NR. Sterile cerebrospinal fluid ascites and chronic peritonitis. N Engl J Med. 2001;345(4):297-298. doi:10.1056/NEJM200107263450417 27. Lee GY, Daniel RT, Jones NR. Ventriculoperitoneal shunt failure as a secondary complication of ovarian hyperstimulation syndrome. Case report. J Neurosurg. 2002;97(4):992-994. doi:10.3171/jns.2002.97.4.0992 28. Yaqoob N, Abbasi SM, Hussain L. Cerebrospinal fluid ascites. Journal of the College of Physicians and Surgeons--pakistan: JCPSP. 2003 May 1;13(5):289-90. 29. Kumar R, Sahay S, Gaur B, Singh V. Ascites in ventriculoperitoneal shunt. The Indian Journal of Pediatrics. 2003 Nov;70(11):859-64. 30. Pawar SJ, Sharma RR, Mahapatra AK, Lad SD, Musa MM. Choroid plexus papilloma of the posterior third ventricle during infancy & childhood: report of two cases with management morbidities. Neurology India. 2003 Jul 1;51(3):379. 31. Olavarria G, Reitman AJ, Goldman S, Tomita T. Post-shunt ascites in infants with optic chiasmal hypothalamic astrocytoma: role of ventricular gallbladder shunt. Child's Nervous System. 2005 May;21(5):382-4. 32. DiLuna ML, Johnson MH, Bi WL, Chiang VL, Duncan CC. Sterile ascites from a ventriculoperitoneal shunt: a case report and review of the literature. Child's Nervous System. 2006 Sep;22(9):1187-93. 33. Kariyattil R, Steinbok P, Singhal A, Cochrane DD. Ascites and abdominal pseudocysts following ventriculoperitoneal shunt surgery: variations of the same theme. Journal of Neurosurgery: Pediatrics. 2007 May 1;106(5):350-3. 34. Paik I, Kotler D, Ganjhu L. Cerebrospinal Fluid Ascites as a Rare Complication of Ventriculo-Peritoneal Shunt: A Case Report: 714. Official journal of the American College of Gastroenterology| ACG. 2010 Oct 1;105:S258. 35. Das S, Bhansali A, Upreti V, Dutta P, Gupta SK, Ananthraman R, Walia R. A child with suprasellar mass and ascites. Case Reports. 2010 Jan 1;2010:bcr0620092030. 36. Montano N, Sturiale C, Paternoster G, Lauretti L, Fernandez E, Pallini R. Massive ascites as unique sign of shunt infection by Propionibacterium acnes. British journal of neurosurgery. 2010 Apr 1;24(2):221-3. 37. Houtman-van Duinen WJ, Ende-Verhaar YM, de Ruiter GC, van der Torren-Conze AM. Cerebrospinal fluid ascites from a ventriculoperitoneal shunt. Nederlands Tijdschrift Voor Geneeskunde. 2011 Jan 1;155(50):A4035-. 38. Mwang’ombe NJ, Thiong’o GM, Boore JK. Cerebrospinal fluid ascites. a case report and literature review. African Journal of Neurological Sciences. 2012;31(1):55-7. 39. Low YY, Thomas J, Wan WK, Ng WH. Brain metastases as a cause of malignant cerebrospinal fluid ascites: case report and review of the literature. CNS Oncol. 2012;1(1):29-37. doi:10.2217/cns.12.2 40. Comba A, Gülenç N, Çaltepe G, Dagçinar A, Yüce Ö, Kalayci AG, Ulus A. Ascites and abdominal pseudocyst: two uncommon ventriculoperitoneal shunt complications in two cases. The Turkish journal of pediatrics. 2013 Nov 1;55(6):655. 41. Woodfield J, Magdum S. Failure of peritoneal and gallbladder shunts in a child with craniopharyngioma. Journal of pediatric neurosciences. 2013 Sep;8(3):221. 195 Delayed cerebrospinal fluid ascites following ventriculoperitoneal shunt 42. Jamal H, Abrams G. A corny cause of cerebrospinal fluid ascites: A case report and review of literature. SAGE Open Medical Case Reports. 2016 Jul 26;4:2050313X16661961. 43. Siddiqi M, Kesavan A, Siddiqi M. Cerebrospinal fluid ascites as a late complication of ventriculoperitoneal shunt placement. Consultant. 2017;57(11):677-8. 44. Sachan D. Choroid Plexus Papilloma Causing CSF Shunt Ascites: A Rare Presentation. Ann Clin Case Rep. 2017; 2. 2017;1376. 45. Han H, Critelli K, Davis AW, Squires JE, Fox MD. Case 6: Ascites in a 20-year-old Man with Dandy-Walker Syndrome, Hydrocephalus, and Ventriculoperitoneal Shunt. Pediatr Rev. 2017;38(10):494-495. doi:10.1542/pir.2016-0140 46. Musa G, Gots A, Lungu MC, Mutumwa M. Cerebrospinal fluid ascites: a patient case report and literature review. Medical Journal of Zambia. 2018;45(4):230-3. 47. Khan AA, Gondal SS, Sharif MM, Yousaf M, Akhtar N. Outcome of Endoscopic Third Ventriculostomy. Journal of Rawalpindi Medical College. 2018 Mar 30;22(1):4-7. 48. Li DK, Platt JM, Shay JE, Yarze JC. Sterile cerebrospinal fluid ascites presenting as high SAAG ascites: a case report. BMC gastroenterology. 2019 Dec;19(1):1-4. 49. Suleiman SE, Tambovtseva A, Mejery E, Suleiman Z, Alaidy Z. Ventriculoperitoneal Shunt-Associated Ascites: A Case Report. Cureus. 2020 Jun 15;12(6). 50. Alexiou GA, Gavra MM, Ydreos J, Papadopoulos E, Boviatsis EJ. Ascites with elevated CSF protein levels after ventriculoperitoneal shunt surgery in an adult. Case report and systematic literature review. Clinical Neurology and Neurosurgery. 2021 Jan 27;202:106519-. 51. Mathew M, Chikani MC, Okpara SE, Uzoanya MU, Ezemba N, Mezue WC. Challenges in the management of cerebrospinal fluid ascites: a case report. Child's Nervous System. 2022 Feb 17:1-3. 52. Mehta N, Somani V, Shah S, Siddiqui A, Chauhan P. CSF ASCITES POST VP SHUNT AFTER 17 YEARS: CSF ASCITES-A RARE OCCURENCE. Bombay Hospital Journal. 2022 Feb 23;64(1).