LETTER TO THE EDITOR
|Year : 2020 | Volume
| Issue : 3 | Page : 338-340
Shunt ascites in a fourth ventricular choroid plexus papilloma in a young child: An uncommon case
Sumit Bansal1, Ayusman Satapathy1, Suvendu Purkait2, Rabi Narayan Sahu1
1 Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Orissa, India
2 Department of Pathology and Lab Medicine, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Orissa, India
|Date of Submission||19-May-2019|
|Date of Decision||18-Nov-2019|
|Date of Acceptance||29-Mar-2020|
|Date of Web Publication||06-Nov-2020|
Dr. Sumit Bansal
Department of Neurosurgery, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Orissa.
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Bansal S, Satapathy A, Purkait S, Sahu RN. Shunt ascites in a fourth ventricular choroid plexus papilloma in a young child: An uncommon case. J Pediatr Neurosci 2020;15:338-40
Choroid plexus papilloma (CPP) is a benign, uncommon neoplasm of the central nervous system. They are most commonly located in the atrium of lateral ventricles in children and fourth ventricles in adults. In children, a few cases of fourth ventricular CPPs have been reported.,, The most common presentation is with raised intracranial pressure as a consequence of block of cerebrospinal fluid (CSF) pathways and/or overproduction of CSF. An uncommon complication following ventriculoperitoneal (VP) shunt placement in children with CPP is the development of ascites., Authors are presenting such a case of fourth ventricular CPP with shunt ascites in a young child that resolved after removal of tumor.
A 5-year-old boy presented with gait ataxia of 2 months duration with repeated episodes of vomiting for 3 days. He was conscious but drowsy. Computed tomography (CT) head was carried out, which showed midline posterior fossa lesion with hydrocephalus. Magnetic resonance imaging (MRI) brain with contrast revealed fourth ventricular lesion with homogeneous contrast enhancement with hydrocephalus, suggestive of fourth ventricular CPP. A VP shunt was carried out after which he improved in sensorium. He developed abdominal distension after shunt surgery. Ultrasonography and X-ray of abdomen revealed ascites that resolved after exteriorization of shunt. Next day, patient was taken up for definitive tumor surgery. Midline suboccipital craniotomy was carried out and using telovelar approach, total excision of fourth ventricular tumor was carried out. Tumor was soft, friable, and highly vascular with good plane of cleavage from normal brain parenchyma. Tumor was arising from tela choroidea present over the dorsal surface of ponto-medullary junction. Intraoperative blood loss was 700mL. Postoperative period was uneventful and later exteriorized shunt was removed also. Histopathological analysis confirmed the diagnosis of CPP (World Health Organization [WHO] Grade I) [Figure 1] and [Figure 2].
|Figure 1: Plain CT head showing hypodense midline posterior fossa lesion (A) with hydrocephalus (B). Ventricles were decompressed after VP shunt (C). Contrast MRI brain showed intense, homogeneous enhancement of the lesion in the fourth ventricle [axial (D), coronal (E), and sagittal (F)]. CT head showing hydrocephalus (G) with ascites revealed on X-ray abdomen (H). Postoperative CT head showing total excision of tumor with resolution of hydrocephalus (I)|
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|Figure 2: Photomicrographs showing a tumor with papillary architecture. The papillae are lined by cuboidal calls having round nucleus and moderate cytoplasm. No mitotic activity or necrosis seen. Findings were suggestive of choroid plexus papilloma. [H and E ×40 (A), H and E ×100 (B), and H and E ×400 (C)]|
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Shunt ascites is a rare complication of CSF shunting surgery. Such a complication due to CSF overproduction and CSF ascites may occur due to choroid plexus hypertrophy and other benign tumors, for example, optic-hypothalamic glioma or CPP. Shunt ascites may occur within a few days to many months after shunt insertion, depending on the amount of CSF production and peritoneal absorption capacity. It appears that younger children tend to develop ascites earlier owing to lesser absorptive surface.
Surgical removal of tumor is the treatment of choice. Options from management of hydrocephalus are VP or ventriculoatrial (VA) shunt. Shunt ascites can be managed by exteriorization and revision of shunt catheter or conversion to VA shunt. Sometimes spontaneous resolution of hydrocephalus after tumor excision is also known as seen in our case. Long-term outcome is excellent after complete removal of tumor.
| References|| |
Prasad GL, Mahapatra AK Case series of choroid plexus papilloma in children at uncommon locations and review of the literature. Surg Neurol Int 2015;6:151.
Fujio S, Hirano H, Kawano H, Hanaya R, Oyoshi T, Niiro M, et al
. [Three pediatric cases with choroid plexus papilloma in the fourth ventricle]. No Shinkei Geka 2010;38:149-55.
Jaiswal AK, Jaiswal S, Sahu RN, Das KB, Jain VK, Behari S Choroid plexus papilloma in children: diagnostic and surgical considerations. J Pediatr Neurosci 2009;4:10-6.
Mohindra S, Savardekar A Management problems in a case of third ventricular choroid plexus papilloma. J Pediatr Neurosci 2012;7:40-2.
Kumar R, Sahay S, Gaur B, Singh V Ascites in ventriculoperitoneal shunt. Indian J Pediatr 2003;70:859-64.
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. Neurol India 2003;51:379-82.
[Figure 1], [Figure 2]