CASE REPORT:
A 10-year-old child presented with a one-day history of headache and vomiting, followed by altered sensorium. He was not taking any medications and had no history of trauma. There was no history of perinatal complications, all vaccinations were administered on schedule, with timely achievement of developmental milestones. Upon initial examination, the patient did not exhibit fever, rash, or meningeal symptoms. He was hemodynamically stable, had a clear airway, and was breathing normally; his Glasgow coma scale was E3V2M3, both pupils were equally reactive to light with a size of 4mm, and no papilledema or neck stiffness. However, following admission, the patient’s Glasgow Coma Scale score deteriorated to E1V1M3 with pupils reacting to light bilaterally equally, necessitating intubation and elective ventilation.
The results of various medical tests, including complete blood count, measurements of urea and electrolyte measures, C-reactive protein levels, glucose levels, liver function tests, and clotting profiles, were within normal ranges. Initial brain scan using computed tomography (CT) revealed a recent bleeding episode in the fourth ventricle with obstructive hydrocephalus. No bleeding was observed within the brain tissue itself or in the subarachnoid space. The magnetic resonance imaging (MRI) brain confirmed the findings and magnetic resonance angiography (MRA) revealed no vascular abnormality (Figure 1A-F ).
Emergency External Ventricular Drain (EVD) insertion was performed following which his GCS improved to E3VtM5. After 6 hours, he was extubated and the next day his GCS was E4V5M6. On day 6, his external ventricular drain was changed to ventriculoperitoneal shunt. The post-procedure period was uneventful, and a repeat CT scan done showed resolving hematoma inside the fourth ventricle. At the time of discharge, the patient was symptomatically better, neurologic status improved and GCS E4V5M6, without any neurologic deficit to the patient. Post discharge, the child was closely monitored and was asymptomatic. A repeat CT taken after 60 days showed complete resolution of hematoma and a CT brain with angiogram done after 2 months (Figure 2A and 2B ) ruled out any vascular anomalies.