Scalp injuries- Explained by Dr Saad Andalib ( A review article).



 Scalp hematomas:


Scalp hematomas are an important indicator of potential TBI, especially when they appear in younger infants (eg, <6 months of age), are larger (eg, >3 cm), and are located in the temporal, parietal, or occipital regions.






Hematomas of the neonates:


Introduction:

Neonatal hematomas refer to a grouping of extracranial injuries that occur during delivery and are secondary to edema or bleeding into the varying locations within the scalp and skull.



Caput Succedaneum:



  • Edematous region above the periosteum that crosses suture lines
  • Presents at birth, typically after prolonged or difficult labor due to compression against bony prominence of maternal pelvis
    • Visualize pitting edema on physical exam
    • Discoloration may be present
  • Usually resolves within a few days and requires no further treatment
  • Complications to look out for include long term scarring and alopecia
    • Halo scalp ring is an alopecic ring that can develop after resolution.


Cephalohematoma:



  • Subperiosteal bleed due to rupture of vessels beneath the periosteum
  • Presents right after delivery as swelling that does NOT cross suture lines
    • Can have some discoloration
  • More common when forceps or vacuum delivery is performed
  • Usually doesn’t expand after delivery
    •  If one notices expansion pursue imaging and work up for source of continuing bleed
  • Resolves spontaneously over course of a few weeks
    • May cause indirect hyperbilirubinemia due to absorption of the bleed
  • Monitor for calcification and ossification, which can result in deformity of skull
  • If the cephalohematoma becomes erythematous and fluctuant, infection might be present
    • Most commonly due to E. coli infection
    • Must do incision and drainage of abscess and debridement of necrotic skull if needed.


Subgaleal hematoma:



  • Bleed located between periosteum of skull and the aponeurosis
  • Presents as fluctuant swelling of the head that may shift with movement
    • Rapid loss of intravascular volume causes tachycardia and pallor
    • Potential for loss of 20-40 percent of neonate’s blood volume
  • Most are due to vacuum-assisted delivery, so monitor for following those deliveries
    • Develops around 12-72 hours after delivery
  • Early recognition is most important for survival
  • Once suspected, monitor by serial measurements of hematocrit and frontal circumference
    • Volume resuscitation with packed red blood cells, fresh frozen plasma, and normal saline to stabilize vitals
    • May need surgical evacuation.

 

References

  1. Chang, H. Y., Peng, C. C., Kao, H. A., Hsu, C. H., Hung, H. Y., & Chang, J. H. (2007). Neonatal subgaleal hemorrhage: clinical presentation, treatment, and predictors of poor prognosis. Pediatrics International, 49(6), 903-907.
  2. Ferriero, D. M. (2004). Neonatal brain injury. New England Journal of Medicine,351(19), 1985-1995.
  3. McKee, T. M. (2015). Neonatal birth injuries. Uptodate.
  4. Nicholson, L. (2007). Caput Succedaneum and Cephalohematoma: The Cs that Leave Bumps on the Head. Neonatal Network, 26(5), 277-281.








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