DISCUSSION:
Primary intraventricular hemorrhage (PIVH) is an uncommon condition
characterized by bleeding within the ventricles of the brain, lacking
any parenchymal or subarachnoid bleeding. While there is a growing body
of research on PIVH in adults, the understanding of this condition in
the pediatric population remains limited. This case report presents a
10-year-old child with PIVH, shedding light on the clinical presentation
and management challenges.
This scarcity of studies has made it difficult to consistently identify
characteristic features of PIVH in children. Headache has consistently
been reported as the most frequent presenting symptom in patients,
followed by vomiting and loss of consciousness [2.3]. In contrast, a
study by Weinstein et al. found altered mental status to be the most
commonly reported presenting symptom, followed by headache and nausea
[1]. These findings align with our case, where the child initially
presented with headache and vomiting, and altered sensorium. In adult
populations, hypertension has been identified as the most common
etiology for PIVH [1,4]. However, the etiology of PIVH in children
differs from that in adults. Vascular malformations, such as
arteriovenous malformations (AVMs), Moya Moya disease, and aneurysms,
can lead to intraventricular hemorrhage in children [2]. Other
potential etiologic factors include coagulopathies, choroid plexus
tumors and cysts, and arteritis. It is crucial to consider these
underlying causes when evaluating pediatric patients with PIVH.
Management strategies for primary intraventricular hemorrhage (PIVH) in
pediatric patients pose significant challenges, as there is limited
research specific to this population. In the case presented, an external
ventricular drain (EVD) was inserted to alleviate obstructive
hydrocephalus. EVD is a commonly employed method for draining
cerebrospinal fluid and reducing intracranial pressure in PIVH cases.
However, it is worth noting that EVD alone may be insufficient, as blood
clots often occlude the drain [5]. In a study by Guo et al.,
surgical intervention was the predominant treatment modality, with
83.3% of patients undergoing surgical procedures, while the remaining
received conservative treatment [2]. The management of PIVH with
obstructive hydrocephalus involves the placement of an external
ventricular drain (EVD) and is the preferred method of treatment
[2]. In cases involving arteriovenous malformations (AVMs), various
surgical interventions, such as resection, endovascular embolization, or
stereotactic radiation, were employed [2]. PPIVH patients diagnosed
with aneurysms were subjected to a combined treatment approach involving
the placement of an external ventricular drain (EVD) and subsequent
endovascular embolization [2]. Notably, ventriculoperitoneal
shunting was not employed as part of the management strategy for any of
the pediatric patients in this study [2].
Certain prognostic factors play a significant role in determining the
outcome of PIVH. In particular, the initial level of consciousness,
presence of early hydrocephalus, and timely diagnosis of intracranial
aneurysms can adversely affect patient outcomes. These factors may lead
to severe neurological deficits and increased mortality rates. Further
research is needed to identify additional prognostic indicators specific
to pediatric PIVH cases, allowing for improved risk stratification and
tailored management approaches.
While the presented case report highlights the successful management and
favorable outcome in the reported patient, it is important to
acknowledge the limitations of this study. One significant limitation is
the limited comparative analysis, which is also due to the limited
availability of literature on PPIVH. This prevents a comprehensive
understanding of the condition and its management options. Future
studies should aim to address this gap by conducting larger-scale
investigations and drawing comparisons with similar cases in the
literature.