Non-traumatic, spontaneous cerebellar hemorrhages in the pediatric age group are rare and usually caused by vascular malformations or hematologic abnormalities. Brain tumors are likewise uncommon, but is the second most common malignancy in children. Low grade tumors are rarely associated with a hemorrhagic onset. We present a case of a previously healthy 16-year-old Filipino adolescent who presented with sudden onset severe headache associated with dizziness and vomiting. Examination revealed only horizontal nystagmus. Her mother died of acute intracranial hemorrhage from an aneurysm, which prompted suspicion of a similar vascular malformation. A non-contrast cranial computed tomography (CT) scan revealed posterior fossa hemorrhage with obstructive hydrocephalus. Subsequent CT angiography revealed no vascular abnormalities. Cranial magnetic resonance imaging (MRI) showed subacute cerebellar hemorrhage and a cavernous malformation was suspected. She underwent craniotomy and gross total excision of the mass. Intraoperative findings showed a yellowish-brown mass with hemorrhages. Histopathologic analysis of the specimen obtained showed a pilocytic astrocytoma. A review of cases showed only 15 cases of pediatric patients with cerebellar pilocytic astrocytoma presenting with intratumoral hemorrhage at the onset. About 47% underwent CSF diversion during or after excision, including our patient. Eighty percent survived with good outcomes. This is an atypical presentation of a low-grade cerebellar tumor which usually has a protracted course. Recognition of this uncommon presentation is important. Pilocytic astrocytoma should be considered in the differential diagnosis of pediatric patients presenting with acute onset cerebellar hemorrhage and tumors manifesting with hemorrhagic onset.

Patricia Orduña
University of the Philippines - Philippine General Hospital
Philippines

Mairre James Gaddi
University of the Philippines - Philippine General Hospital
Philippines