SUBGALEAL Sarah Meyers MS4 Ilse Castro-Aragon MD CASE HISTORY

Ex-FT (37w6d) male born by low transverse C-section for arrest of descent and to a 34-year-old G2P1 mother. The infant had 1- and 5-minute APGAR scores of 9 and 9, weighed 3.625 kg (54th %ile), and had a head circumference of 34.5 cm (30th %ile). Following a challenging delivery of the head during C/s, the infant was noted to have left-sided parietal and occipital bogginess, and an ultrasound was ordered due to concern for subgaleal hematoma. PEDIATRIC HEAD ULTRASOUND: SUBGALEAL HEMATOMA

Superficial pediatric head ultrasound showing moderately echogenic fluid collection (green arrow), superficial to the periosteum (blue arrow), crossing the sagittal suture (red arrow).

Findings on U/S consistent with large parieto-occipital subgaleal hematoma. PEDIATRIC HEAD ULTRASOUND: SUBGALEAL HEMATOMA

Superficial pediatric head ultrasound showing moderately echogenic fluid collection (green arrow), consistent with large parieto-occipital subgaleal hematoma. CLINICAL FOLLOW UP

- Subgaleal hematoma was confirmed on ultrasound and the infant was transferred from the newborn nursery to the NICU for close monitoring, including hourly head circumferences and repeat hematocrit measurements - Serial head circumferences remained stable around 34 cm and hematocrit remained stable between 39 and 41 throughout hospital course - The infant was subsequently treated with phototherapy for hyperbilirubinemia, thought to be secondary to resorption of the SGH IN A NUTSHELL: SUBGALEAL HEMATOMA • Major Criteria • Collection of fluid superficial to the periosteum (thus, may cross suture lines) • Blood of moderate echogenicity • Minor Criteria • Decreasing echogenicity over time • Potential Complications • Potential for and/or massive hemorrhagic shock – with SGH can lose up to 40 percent of their blood volume in this potential space • Remember • To have a high index of suspicion for SGH, especially after or vacuum/forceps delivery • To monitor for hyperbilirubinemia, coagulopathy, and early signs of volume loss in these newborns SUBGALEAL HEMATOMA: CLINICAL FINDINGS

Boggy, erythematous swelling on the head of the newborn, primarily in the occipital area, that shifts with head movement and may expand quickly after delivery

Image courtesy of Dr Kewal Arunkumar Mistry, Radiopaedia.org, rID: 35576 DIFFERENTIAL DIAGNOSIS: Scalp hematoma in a newborn

• : supra-periosteal between the skin and the galea aponeurosis; may cross suture lines; typically resolves spontaneously without significant volume loss • : sub-periosteal bleeding caused by rupture of vessels beneath the periosteum; does not cross suture lines; typically resolves spontaneously without significant volume loss • Subgaleal hematoma: bleeding between the periosteum and galea aponeurosis due to shearing of emissary veins; may cross suture lines; potential for massive blood loss requiring volume resuscitation with packed RBCs and FFP Visualizing scalp in newborns

Image courtesy of Wikipedia (Scalp hematomas) Imaging Spectrum of Disease: Cephalohematoma

Head CT showing bilateral cehalomatomas (green arrows) – note that the cephalohematomas do not cross suture lines.

Case courtesy of Dr Fakhry Mahmoud Ebouda, Radiopaedia.org, rID: 26778 Imaging Spectrum of Disease: Cephalohematoma

Superficial pediatric head ultrasound showing hyperchoic fluid collection (green arrow) superficial to the periosteum, lifted (blue arrow), consistent with cephalohematoma. Image Spectrum of Disease: Subgaleal Hematoma Head MRI showing fluid collection superficial to the periosteum (orange arrow), extending downward from the occiput, in an infant with subgaleal hematoma. Visualized in the sagittal plane. Image Spectrum of Disease: Subgaleal Hematoma Superficial pediatric head ultrasound showing moderately echogenic fluid collection (green arrow), crossing the lambdoid suture (red arrow) in a patient with an occipital subgaleal hematoma. Thickening of the skin (blue star) consistent with caput succedaneum. Caput succedaneum

Typically Can cross firm on suture lines exam Risk factors: birth trauma, vacuum/forceps delivery

Cephalohematoma Subperiosteal Subgaleal hematoma bleeding DISCUSSION

• Though ultrasound is often the first modality used due to easy and rapidity of access, brain CT or MRI should always be considered in evaluation of a newborn with clinically significant subgaleal hematoma • The potential space for blood loss in SGH is bordered anteriorly by the orbital ridges, posteriorly by the nape of the neck, and laterally by the ears. • Up to 260 mL of blood can accumulate in this space! • Mortality is most often associated with coagulopathy and/or severe DISCUSSION • The potential for significant blood loss and hemorrhagic shock is high in newborns with subgaleal hematoma – early diagnosis and treatment is crucial! • The presence of fluctuance early on is an important distinguishing feature of subgaleal hemataoma • Much boggier on exam than caput or cephalohematoma • After all vacuum/forceps deliveries, newborns should be monitored for a minimum of 8 hours, regardless of APGAR scores or need for resuscitation • Monitoring should include hourly vital signs and head circumference measurements, as well as Hb/Hct and coagulation studies ASAP and subsequently every 6 hours OLA

Following a vacuum delivery, a 40-week-old female infant with 1- and 5-minute APGAR scores of 6 and 8 is noted to have left-sided parietal and occipital bogginess on head exam. This finding, given the infant’s history, is most concerning for:

A) Caput succedaneum B) Cephalohematoma C) Subgaleal hematoma D) All of the above OLA

Infants with scalp bleeds, including caput succedaneum, cephalohematoma, and subgaleal hematoma, are at increased risk for the development of:

A) Hypoglycemia B) Hyperbilirubinemia C) Hemorrhage D) No increased risk OLA

Because blood spreads through a large tissue plane, blood loss may be significant before hypovolemia becomes clinically relevant (pallor, tachycardia, ) in:

A) Caput succedaneum B) Cephalohematoma C) Subgaleal hematoma D) All of the above OLA

Following delivery by C-section for failure to progress, a superficial head ultrasound is ordered for 38-week-old female infant with APGAR scores of 8 and 9, weighing 3.5 kg and with a head circumference of 35 cm, due to abnormal findings on head exam. The ultrasound reveals a fluid collection that does not cross suture lines, consistent with:

A) Caput succedaneum B) Cephalohematoma C) Subgaleal hematoma D) All of the above LINKS AND REFERENCES • Davis DJ. Neonatal : diagnosis and management. CMAJ. 2001 May 15;164(10):1452-3. PMID: 11387919; PMCID: PMC81073. • Kilani RA, Wetmore J. Neonatal subgaleal hematoma: presentation and outcome-- radiological findings and factors associated with mortality. Am J Perinatol. 2006 Jan;23(1):41-8. • McKee-Garrett TM. Neonatal Birth Injuries. nI UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2014. Accessed October 23, 2020. • Radiopaedia: Caput succedaneum. https://radiopaedia.org/cases/caput- succedaneum • Radiopaedia: Cephalohematoma. https://radiopaedia.org/articles/cephalohaematoma?lang=us • Radiopaedia: Subgaleal hematoma due to birth trauma. https://radiopaedia.org/articles/subgaleal-haematoma-2?lang=us