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.