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\begin{document}

\title{Aseptic ascites and chemical meningitis following ventriculoperitoneal
shunting for craniopharyngioma: a first case report}



\author[1]{Ghassen Gader}%
\author[1]{Skander Guediche}%
\author[1]{Mouna Rkhami}%
\author[2]{Ihsèn Zammel}%
\author[2]{Mohamed Badri}%
\affil[1]{Université de Tunis El Manar Faculté de Médecine de Tunis}%
\affil[2]{Universite de Tunis El Manar Faculte de Medecine de Tunis}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\selectlanguage{english}
\begin{abstract}
This case is about a child who had a ventriculoperitoneal shunt due to a
hydrocephalus related to a cystic craniopharyngioma. Postoperative, he
presented abdominal distension and meningismus. Imaging showed
regression of the tumor. The cyst was drained by the shunt. No previous
similar situations was reported in the literature.%
\end{abstract}%



\sloppy


\textbf{Aseptic ascites and chemical meningitis following
ventriculoperitoneal shunting for craniopharyngioma: a first case
report}

\selectlanguage{ngerman}\textbf{Ghassen Gader \textsuperscript{*}, Skander Guediche, Mouna
Rkhami, Ihsèn Zammel, Mohamed Badri}

Ghassen Gader (correspondant author): University of Tunis-El Manar,
Faculty of Medicine of Tunis. Department of Neurosurgery, Trauma and
Burns Center, Ben Arous, Tunisia. Mailing address: Avenue Faycel Ibn
Abdelaziz, PO Box 152, Hammamet 8050, Tunisia. Mail:
ghassgader@gmail.com. Phone: 0021698604749. Fax: 0021672260812.

Skander Guediche: University of Tunis-El Manar, Faculty of Medicine of
Tunis. Department of Neurosurgery, Trauma and Burns Center, Ben Arous,
Tunisia.

Mouna Rkhami: University of Tunis-El Manar, Faculty of Medicine of
Tunis. Department of Neurosurgery, Trauma and Burns Center, Ben Arous,
Tunisia.

Ihsèn Zammel: University of Tunis-El Manar, Faculty of Medicine of
Tunis. Department of Neurosurgery, Trauma and Burns Center, Ben Arous,
Tunisia.

Mohamed Badri: University of Tunis-El Manar, Faculty of Medicine of
Tunis. Department of Neurosurgery, Trauma and Burns Center, Ben Arous,
Tunisia.

Written informed consent was obtained from the patient to publish this
report in accordance with the journal's patient consent policy



\textbf{Aseptic ascites and chemical meningitis following
ventriculoperitoneal shunting for craniopharyngioma: a first case
report}

\textbf{Key clinical message:}

Craniopharyngioma's cyst rupture is an unusual complication of
ventriculoperitoneal shunt. This benign inadvertance should be
recognised as it may explain the onset of some unexpected clinical signs
in the follows of this procedure.

\textbf{Abstract:}

This case is about a child who had a ventriculoperitoneal shunt due to a
hydrocephalus related to a cystic craniopharyngioma. Postoperative, he
presented abdominal distension and meningismus. Imaging showed
regression of the tumor. The cyst was drained by the shunt. No previous
similar situations was reported in the literature.

\textbf{Keywords:}

Craniopharyngioma; Ventriculoperitoneal shunt; Ascites; Meningitis;
Neurosurgery

\textbf{Introduction~:}

Craniophayngiomas are epithelial tumors, developing from the remnants of
the Rathke pouch, and expending within the sellar and supra-sellar
areas. Despite their benign histological nature, their propensity to
infiltrate surrounding tissues, as well as their close proximity to the
pituitary stalk, hypothalamus, optic chiasm, carotid arteries and third
ventricle, may lead to serious morbidities and be source for therapeutic
difficulties (1,2).

Some craniopharyngiomas, mainly of retrochiasmatic development, may
compress the third ventricle or even the foramina of Monroe and cerebral
aqueduct, leading to an upward hydrocephalus. This complication, added
to the volume of the tumor, may be source of an important intracranial
hypertension. Thus, a cerebrospinal fluid (CSF) shunting may be
mandatory before resection of the tumor (3,4).

In this paper, we report the case of a child who underwent a
ventriculoperitoneal (VP) shunting as he presented a hydrocephalus
related to a craniopharyngioma. The ventricular catheter perforated the
cyst which expressed through an aseptic ascites and a chemical
meningitis. To the best of our knowledge, this is the first case to be
reported for such an inadvertence.

\textbf{Case report:}

A 4-year-old male child, who had no pathologic background, presented due
to the progressive onset since 1 month of headaches, vomiting, visual
blur and diplopia. On physical examination, the patient was fully
conscious, presented a 6\textsuperscript{th} cranial nerve palsy without
any motor or sensitive deficit. Fundus examination found a grade 2
papilledema. Brain CT scan (Figure n°1) showed a sellar and supra sellar
cystic tumor, surrounded by calcifications disposed on its wall. The
lesion was responsible for an important mass effect on the third
ventricle thus an upward hydrocephalus. A brain MRI (Figure n°2) was
also performed showing that this lesion was hypointense on T1-weighted
imaging (WI), hyperintense on T2-WI, and slightly enhancing on its
fleshy component after injection of Gadolinium. The tumor filled the
optico chiasmatic cistern, pushed forward the optic chiasm, and
compressed the roof of the 3\textsuperscript{rd} ventricle. Biological
and hormonal assessment showed no signs for any endocrinologic
dysfunction.

Due to the major hydrocephalus, the decision was first to perform a CSF
shunting in order to decrease the intracranial pressure and facilitate
an ulterior resection of the tumor. A VP shunt was performed without any
peroperative or postoperative inadvertence. Following the surgery, the
patient presented a complete resolution of the symptoms, and he was
discharged 3 days after surgery.

Four days after discharge, the patient represented for the onset of a
low grade fever (38°), headaches, and abdominal distension, with an
unchanged neurological status. Physical examination revealed a stiff
neck and an abdominal shifting dullness.

Brain CT scan (Figure n°3) showed a significant regression of the volume
cystic portion as well as a complete resolution of the hydrocephalus.
Abdominal CT scan (Figure n°4) showed an abundant intra-abdominal fluid
collection without any evidence septa or partitions.

A lumbar puncture was performed, showing a hyperproteinorrachia (2,5
g/l), a hypercytosis (40 elements/mm3) and a normoglucorrachia. A
puncture of the ascites was also done. This liquid contained contained 6
g of protein per 100ml. Cytologic examination was negative for tumor
cells. Both cultures were sterile after 72 hours.

The decision received corticosteroids with observation of the clinical
evolution. The boy presented a total regression of both fever and
abdominal symptoms. The ascites was completely resorbed as shown by
ultrasound.

The patient was discharged after 10 days. Viewing the actual clinical
and radiological status of the patient, related to a quasi totally
calcified non voluminous supra sellar mass without any major visual or
endocrinologic impairment, a regular follow up is planned. Surgery will
be discussed in case of clinical or radiological evidence of tumoral
progression.

\textbf{Discussion:}

Aseptic meningitis following peroperative extravasation of the content
of cystic craniopharyngioma is a well known complication. It is related
to an irritation of the subarachnoid spaces by the cyst fluid. Thus,
facing a cystic craniopharyngioma, a careful aspiration of its content
is recommended before any further manipulation of the walls. Spontaneous
rupture of craniopharyngioma cyst after VP shunting is a very uncommon
situation, as we have not found any similar reports within the
literature (2,5,6).

The patient described here had meningismus and abdominal distension due
to ascites with both peritoneal and cerebrospinal fluids. This indicates
that he had aseptic meningitis due to the leak of the cystic content of
the craniopharyngioma, which passed through the VP shunt into the
abdominal cavity causing a peritoneal irritation and a reactive ascites.

The presumed explanation for this inadvertence is that the intracranial
hypotension induced by the onset of the VP shunt, created a pressure
gradient between the ventricules and the cyst. Thus, the liquid passed
through tumor capsule and anterior wall of third ventricle, then to the
peritoneal cavity through the abdominal catheter of the VP shunt.

Clinical improvement and disappear of the abdominal collection are
presumably due to cessation of discharge of the cystic contents of the
craniopharyngioma.

\textbf{Conclusions:}

It would seem to be reasonable to suggest that in case of meningismus
and abdominal collection after VP shunting of a cystic craniopharyngioma
to suspect and confirm aspetic menigitis and cystic fluid passage in
peritoneal cavity after elimination of infectious complications. Follow
up may be a good option since spontaneous resolution is a possibility.

\textbf{Figures:}

Figure n°1: Axial sections of a brain CT scan without injection showing
a suprasellar cystic lesion surrounded by calcifications responsible for
an hydrocephalus

Figure n°2: Axial (A), sagittal (B) and coronal (C) sections of a brain
MRI on T2-WI (A), T2 Flair-WI (B) and T1-WI with injection of Gadolinium
showing a suprasellar cystic mass compressing the floor of the third
ventricle thus a hydrocephalus.

Figure n°3: Axial section of a postoperative brain CT scan showing a
regression of the cystic portion and persistence of the calcifications,
as well as a contact between the ventricular tip of the VP shunt and the
cystic wall.

Figure n°4: Abdominal CT scan showing an ascites in which the peritoneal
tip of the VP shunt is visible.

\textbf{Authors contribution:}

Ghassen Gader: wrote the manuscript Skander Guediche: collected
iconographic data Mouna Rkhami: performed bibliographic research Ihsèn
Zammel and Mohamed Badri: corrected the manuscript

\textbf{References:}

1. Rajan VTT. Spontaneous Intra-Parenchymal Rupture of Craniopharyngioma
-- A Rare Phenomenon. J Clin Diagn Res. 2017;11(7):10\selectlanguage{english}-2.

2. Takahashi T, Kudo K, Ito S, Suzuki S. Spontaneously ruptured
craniopharyngioma cyst without meningitic symptoms --two case reports.
Neurol Med Chir. 2003;43(3):150\selectlanguage{english}-2.

3. Maeda T, Kazumi T, Hotta K, Ishida Y, Yoshida M, Ijichi A, et al.
Aseptic Localized Peritonitis in a Patient with Chemical Meningitis
Associated with Craniopharyngioma Cysts. Intern Med. 1993;32(4):340\selectlanguage{english}-2.

4. Vakharia K, Siasios ID, Dorsch A, Leondrdo J. Spontaneous
intraventricular rupture of a craniopharyngioma cyst: A case report. Int
J Crit Illn Inj Sci. 2017;7(2):126\selectlanguage{english}-8.

5. Chro\selectlanguage{polish}ś\selectlanguage{english}ci\selectlanguage{polish}ń\selectlanguage{english}ska-Krawczyk M, Zienkiewicz E, Podkowi\selectlanguage{polish}ń\selectlanguage{english}ski A, Klatka M.
Chemical meningitis in children as a risk factor following
craniopharyngioma resection -- a case report. BMC Neurol. d\selectlanguage{ngerman}éc
2020;20(1):56.

6. Adegbite A, Khan M. Role of protein content in CSF ascites following
ventriculoperitoneal shunting. J Neurosurg. 1982;57(3):423\selectlanguage{english}-5.\selectlanguage{english}
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