Clinical
Presentation: Patient 1 is a 10-day-old infant with fluid collection over the right scalp after birth. Patient 2 is a 5-month-old infant who presented with skull deformity.
Imaging Findings: Patient 1 has a large area of soft tissue attenuation fluid with focal areas of high attenuation consistent with subacute subgaleal hematoma.
Patient 2 has prominence of the bilateral parietal regions on the skull with underlying extra-axial fluid collection and calcified inner membrane compatible with bilateral parietal internal cephalohematomas.
Figure 1: Patient 1 - Axial CT image of subgaleal hematoma in brain window.
Figure 2: Patient 1 - Coronal CT image of subgaleal hematoma in brain window.
Figure 3: Patient 2 - Axial CT image of parietal calcified cephalohematoma in brain window.
Figure 4: Patient 2 - Coronal CT image of bilateral calcified parietal cephalo-hematomas in soft tissue window.
Diagnosis:Birth trauma: Patient 1: subgaleal hematoma and Patient 2: cephalohematoma
Discussion: Birth trauma results from mechanical forces during labor and delivery. Most are self-limiting and have good outcomes. Risk factors include large-for-date infants, infants weighing more than 4.5 kilograms, instrumental deliveries (forceps or vacuum), breech delivery and traction.
Subgaleal hematoma is bleeding in the potential space beneath the scalp galea aponeurosis superficial to the skull. The aponeurosis is found beneath the occipitofrontalis muscle. Most cases result from vacuum applied to the head at delivery. Subgaleal hematoma typically develops over twelve hours to three days after delivery. If severe, this can be seen immediately after birth.
On physical exam, subgaleal hematoma is a fluctuant, firm mass superficial to the scalp. Swelling may obscure the fontanelle and cross suture lines, differentiating it from cephalohematoma.The hematoma spreads and may dissect into the subcutaneous tissues of the neck. Patients presenting with hemorrhagic shock have a poorer prognosis.
Management of subgaleal hematoma consists of observation. These lesions commonly resolve over two to three weeks. Imaging is usually not performed.
Cephalohematoma is a traumatic subperiosteal hemorrhage secondary to rupture of blood vessels between the skull and the periosteum. These usually increase in size after birth.
On physical exam, cephalohematoma is a firm, tense mass. Suture lines delineate its extent.
Skull radiography or CT scanning are indicated for cephalohematoma if there are neurologic symptoms or suspicion of fracture. On CT or MR, these may appear as crescent-shaped lesions adjacent to the skull’s outer table. Some calcify. MR appearance is of subacute blood with hyperintense T1 and T2 signal. If imaged acutely, there may be hypointense T2 signal.
Patients with cephalohematoma are usually observed. These typically disappear over months of skull growth and remodeling. There may be residual calcification. Cephalohematoma is a risk factor for posterior deformational plagiocephaly.
For both subgaleal hematoma and cephalohematoma, laboratory work may indicate decrease in hematocrit and hyperbilirubinemia secondary to breakdown of blood products. Coagulopathy work-up may be indicated in some cases.
References:
Barkovich A. Pediatric Neuroimaging. Lippincott, Williams & Wilkins: New York, 2000.
Morón FE, Morriss MC, Jones JJ, Hunter JV. Lumps and bumps on the head in children: use of CT and MR imaging in solving the clinical diagnostic dilemma. Radiographics. 2004 Nov-Dec;24(6):1655-74. [Medline]
Peitsch WK, Keefer CH, LaBrie RA, Mulliken JB. Incidence of cranial asymmetry in healthy newborns. Pediatrics. 2002 Dec;110(6):e72. [Medline]
