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Neurology India, Vol. 53, No. 3, July-September, 2005, pp. 373-374 Letter To Editor Idiopathic primary pan intra-ventricular hemorrhage in a child Patwardhan RavishV, Fowler Marjorie, Willis BrianK, Nanda Anil Department of Neurosurgery, Department of Pathology, Louisiana State University Health Sciences Center in Shreveport, Louisian, Date of Acceptance: 18-Jun-2005 Code Number: ni05137 Sir, Primary intraventricular hemorrhage (PIVH) is defined as hemorrhage restricted to the ventricular system without apparent brain parenchymal involvement. Idiopathic PIVH (IPIVH, whereupon no clear evidence of a source is found) has been reported in only six cases, all of whom were adults [1],[2]. We present the case of a 7-year-old female with IPIVH, with pertinent discussion. With a past history of mild headaches over 6 months, this girl awoke with a severe headache and nausea, becoming subsequently unresponsive (with no apparent seizure activity noted). She was rushed to an adjacent hospital where a computed tomography (CT) scan of the head revealed a pan-intraventricular hemorrhage with ventricular dilatation [Figure - 1]. An external ventricular drain (EVD) was placed with an extremely high opening pressure and the CSF was drained continuously. The patient improved post-operatively and over the next 24 hours was able to interact with her parents and follow some commands. A post-EVD placement CT revealed no new bleed, adequate EVD placement, and a right basal ganglia hypodensity. Approximately 36 hours post-presentation, she became acutely unresponsive to central stimulation with fixed and dilated pupils, with the EVD still functional and draining bloody fluid. The patient′s pupils became fixed and dilated, and she was unresponsive to deep central stimulation. No significant vital sign change was noted leading up to the event, and the phenytoin level was slightly supratherapeutic, with no evidence of coagulopathy. Subsequent CT over 8 hours showed no new findings. No seizure activity was ever noted, and the patient never improved. After failing apnea and nuclear medicine blood flow studies, the patient was pronounced brain dead and support withdrawn. At Autopsy, findings were consistent with herniation [Figure - 2] and histopathology revealed no underlying vascular malformation, tumor, or other pathology."Spontaneous" PIVH describes all non-traumatic cases of PIVH and includes hemorrhage related to entities such as vascular malformations, vascular tumors, moyamoya disease, aneurysms, fibromuscular dysplasia, stroke, coagulopathy, and hypertension, along with some idiopathic cases. Survival has ranged from 40-100% according to various series.[3],[4] Idiopathic hemorrhagic stroke has been described in 46% of young patients.[5] Other than EVD placement, few guidelines exist for treatment. The causes of the PIVH and subsequent deterioration remain unclear. An intracranial pressure wave, subsequent hemorrhagic stroke and "suicidal vascular malformation" are all possible but unlikely. The cause of the PIVH in our case remains a mystery in spite of an Autopsy. References
Copyright 2005 - Neurology India The following images related to this document are available:Photo images[ni05137f2.jpg] [ni05137f1.jpg] |
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