NEURORADIOLOGY: Pediatric/Congenital
Case Author: Sumit Pruthi, MBBS, Monroe Carrell Jr. Children’s Hospital at Vanderbilt University
History
2-week-old male infant with a bump on the head.
Imaging Findings
CT scan of the head (A) shows a fluid collection similar to high attenuation in relation to the surrounding tissue along the posterior midline overlying the occipital bone. Ultrasound image of the scalp (B) shows a thick-walled predominantly anechoic fluid collection containing a few small internal echogenic areas. The collection crosses the cranial sutures.
Diagnosis
Subgaleal hematoma
Teaching Points
The three major varieties of extracranial hemorrhage include caput succedaneum, subgaleal hematoma, and cephalohematoma.
Subgaleal hematoma usually results from rupture of emissary veins with blood accumulating between the epicranial aponeurosis of the scalp and the periosteum. The space in which the hematoma forms is called the subaponeurotic space.
The subaponeurotic space is a large potential space that can hold as much as 260 mL of blood.
It extends anteriorly from the orbital ridge to the nuchal ridge in the posterior aspect. Laterally, it extends to the temporal fascia.
In neonates, subgaleal hematoma is most often associated with vacuum extraction and forceps delivery, but it also can occur spontaneously and be massive, particularly if there is associated coagulopathy.
Typically, subperiosteal hematoma/cephalhematoma does not cross cranial sutures because of the firm adherence of periosteum to the suture edge. This feature helps to differentiate subperiosteal hematoma from subgaleal hematoma and caput succedaneum, both of which often cross sutures.
Extracranial hematoma is usually clinically diagnosed and self-limiting, with resolution within weeks with no sequelae; however, large hematomas can cause hemorrhagic shock and death. CT and MRI can show variable findings depending on the stage of hemorrhagic collection and are often performed to exclude or define the extent of intracranial injury.
Suggested Readings
Davis DJ. Neonatal subgaleal hemorrhage: diagnosis and management. CMAJ 2001; 164:1452–1453
Kilani RA, Wetmore J. Neonatal subgaleal hematoma: presentation and outcome—radiological findings and factors associated with mortality. Am J Perinatol 2006; 23:41–48
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