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\begin{document}

\title{PEDIATRIC PRIMARY INTRAVENTRICULAR HEMORRHAGE: A CASE REPORT OF ISOLATED
4TH VENTRICLE HEMORRHAGE IN A 10-YEAR-OLD BOY}



\author[1]{Aswith Das}%
\author[2]{BIJU BHADRAN}%
\author[3]{Vivek Sanker}%
\author[4]{Vinay Suresh}%
\author[5]{Pratik Agarwal}%
\author[6]{Tirth Dave}%
\affil[1]{Government TD Medical College}%
\affil[2]{Trivandrum Medical College}%
\affil[3]{Noorul Islam Institute of Medical Science and Research Foundation Medicity}%
\affil[4]{King George Medical University}%
\affil[5]{Lokmanya Tilak Municipal Medical College and General Hospital}%
\affil[6]{Bukovinian State Medical University}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\textbf{PEDIATRIC PRIMARY INTRAVENTRICULAR HEMORRHAGE: A CASE REPORT OF
ISOLATED 4TH VENTRICLE HEMORRHAGE IN A 10-YEAR-OLD BOY}

\textbf{Aswith Das\textsuperscript{1,2}, Biju
Bhadran\textsuperscript{2,3}, Vivek Sanker\textsuperscript{2,4}, Vinay
Suresh\textsuperscript{2,5}, Pratik Agarwal\textsuperscript{2,6}, Tirth
Dave\textsuperscript{2,7}}

\textsuperscript{\textbf{1}}\textbf{Senior Resident, MCh Neurosurgery,
Govt TDMCH, Alappuzha}

\textsuperscript{\textbf{2}}\textbf{Team Erevnites}

\textsuperscript{\textbf{3}}\textbf{Professor, Department of
Neurosurgery, Government Medical College, Trivandrum.}

\textsuperscript{\textbf{4}}\textbf{Research Fellow, Society of Brain
Mapping and Therapeutics, CA, USA}

\textsuperscript{\textbf{5}}\textbf{King George's Medical University,
Lucknow, India.}

\textsuperscript{\textbf{6}}\textbf{Lokmanya Tilak Municipal Medical
College and General Hospital, Mumbai, India.}

\textsuperscript{\textbf{7}}\textbf{Bukovinian State Medical University,
Chernivtsi, Ukraine.}

\textbf{Corresponding Author:}

Tirth Dave,

Bukovinian State Medical University,

Chernivtsi, Ukraine.

ORCiD: 0000-0001-7935-7333,

Email: tirth.snehal.dave@gmail.com

\textbf{ORCID IDs:}

Vivek Sanker: 0000-0003-0615-8397

Vinay Suresh: 0000-0002-1401-9154

Pratik Agarwal: 0000-0002-1304-8332

Tirth Dave: 0000-0001-7935-7333

\textbf{KEY CLINICAL MESSAGE:}

Primary Intraventricular Hemorrhage (PIVH) is a rare condition in
pediatric patients, presenting with headache, vomiting, and altered
mental status. Surgical interventions, such as External Ventricular
Drain (EVD) placement, followed by ventriculoperitoneal shunting, show
promising outcomes. Further research is needed to enhance understanding
and optimize management strategies for pediatric PIVH.

\textbf{ABSTRACT:}

This case report describes a 10-year-old boy with isolated PIVH in the
fourth ventricle, shedding light on its clinical presentation and
management challenges. The patient presented with headache, vomiting,
and altered sensorium, and was subsequently diagnosed with obstructive
hydrocephalus due to intraventricular bleeding. Emergency External
Ventricular Drain (EVD) insertion was performed, followed by
ventriculoperitoneal shunt placement, resulting in a favorable outcome.
The etiology of PIVH in children differs from that in adults, with
arteriovenous malformations, Moya Moya disease, and aneurysms being
commonly implicated causes. Management strategies for pediatric PIVH are
challenging due to limited research, but EVD placement and surgical
interventions have shown promise.

\textbf{KEYWORDS:} \textbf{Pediatric Intraventricular hemorrhage,
Pediatric Neurosurgery, External Ventricular Drain, Ventriculoperitoneal
Shunt}



\textbf{INTRODUCTION:}

Primary Intraventricular Hemorrhage (PIVH) refers to bleeding that
occurs specifically within the ventricular system of the brain, without
any involvement or bleeding within the surrounding brain tissue. It is a
rare occurrence comprising approximately 3.1\% of non-traumatic central
nervous system hemorrhages {[}1{]}. While there is some literature on
the etiology, clinical features, and management of PIVH in adults, the
understanding of this condition in the pediatric population is limited,
posing challenges in identifying its characteristics and developing
specific management protocols. Available reports suggest that
arteriovenous malformations, Moya Moya disease, and aneurysms are among
the commonly implicated causes in pediatric cases {[}2{]}. Surgery,
particularly the use of an External Ventricular Drain (EVD) to alleviate
intracranial pressure in case of acute hydrocephalus, remains the
primary approach documented in the literature {[}2{]}. Due to the
significant risks of mortality and neurological impairment associated
with primary intraventricular hemorrhage (PIVH), it is imperative to
thoroughly report and discuss the key features of this condition in the
pediatric population. In this context, we present a rare case of
isolated PIVH in the fourth ventricle observed in a 10-year-old boy.

\textbf{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 (\textbf{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 (\textbf{Figure 2A and 2B}
) ruled out any vascular anomalies.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure 1A:} MRI showing isolated hemorrhage in the
4\textsuperscript{th} ventricle. \textbf{1B:} CT scan showing a
hyperdense area of blood density noted within 4th ventricle, likely
Intraventricular hemorrhage. Upstream dilatation of bilateral lateral
and 3rd Ventricle is noted, possibly due to obstructive
hydrocephalus.\textbf{1C:} Susceptibility Weighted Image showing
blooming foci in the 4th Ventricle. \textbf{1D:} T1 weighted image
showing hyperintense area within 4th Ventricle. \textbf{1E, F:} CT scan
taken after VP shunt showing EVD tube in situ with tip in the right
lateral ventricle. Mild hydrocephalus (reduced) seen.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Figure 2A and 2B:} \textbf{CT angiogram taken after resolution
of bleed 2 months after discharge}

\textbf{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.

\textbf{CONCLUSION:}

PIVH in pediatric patients remains a challenging condition due to its
rarity and limited research on this specific population. This case
report adds to the existing knowledge on pediatric primary
intraventricular hemorrhage (PIVH) by providing insights into the
clinical presentation, management approach, and favorable outcome in a
pediatric patient, highlighting the potential efficacy of a combined
strategy involving external ventricular drain (EVD) placement and
subsequent ventriculoperitoneal shunting. However, further research is
warranted to better understand the etiology, prognostic factors, and
optimal management strategies for pediatric PIVH, enabling improved
outcomes for affected children.

\textbf{DECLARATIONS:}

\textbf{LIST OF ABBREVIATIONS:}

PIVH - Primary Intraventricular Hemorrhage

EVD - External Ventricular Drain

CT - Computed Tomography

MRI -- Magnetic Resonance Imaging

MRA - Magnetic Resonance Angiography

AVMs - Arteriovenous Malformations

\textbf{CONFLICTS OF INTEREST:}

None declared.

\textbf{AUTHOR CONTRIBUTION:}

All the authors contributed equally in drafting, editing, revising and
finalizing the case report.

\textbf{ETHICAL APPROVAL:~}

The ethical approval was not required for the case report as per the
country's guidelines.

\textbf{CONSENT:}

Written informed consent was obtained from the patient to publish this
report.

\textbf{DATA AVAILABILITY STATEMENT:}

The data that support the findings of this article are available from
the corresponding author upon reasonable request.

\textbf{REFERENCES:}

1. Weinstein R, Ess K, Sirdar B, Song S, Cutting S. Primary
Intraventricular Hemorrhage: Clinical Characteristics and
Outcomes.\emph{Journal of Stroke and Cerebrovascular Diseases} .
2017;26(5):995-999. doi:10.1016/j.jstrokecerebrovasdis.2016.11.114

2. Guo R, Chen R, Yu Z, et al. Primary Intraventricular Hemorrhage in
Pediatric Patients: Causes, Characteristics, and Outcomes. \emph{World
Neurosurgery} . 2020;133:e121-e128. doi:10.1016/j.wneu.2019.08.145

3. Sannegowda R, Satija V, Srivastava T, Tejwani S, Jain RS, Mathur T.
Primary intraventricular hemorrhage: Clinical features, risk factors,
etiology, and yield of diagnostic cerebral angiography. \emph{Neurol
India} . 2014;62(2):144. doi:10.4103/0028-3886.132333

4. Das AS, Regenhardt RW, Gokcal E, et al. Idiopathic primary
intraventricular hemorrhage and cerebral small vessel
disease.\emph{International Journal of Stroke} . 2022;17(6):645-653.
doi:10.1177/17474930211043957

5. Arboix A, Garc\selectlanguage{ngerman}ía-Eroles L, Vicens A, Oliveres M, Massons J.
Spontaneous Primary Intraventricular Hemorrhage: Clinical Features and
Early Outcome. \emph{ISRN Neurology} . 2012;2012:1-7.
doi:10.5402/2012/498303

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