Delayed Extensive Subgaleal Hematoma Following Minor Head Injury

01/09/2014 00:00:00

Delayed Extensive Subgaleal Hematoma Following Minor Head Injury

Amit Agrawal1, Akshay Pratap2, Alin Sundas1, Abhishek Tiwari3.
1Department of Neurosurgery, B.P. Koirala Institute of Health Sciences, Dharan, Nepal,
2Pediatric Surgery, B.P. Koirala Institute of Health Sciences, Dharan, Nepal,
3Department of Radiology, B.P. Koirala Institute of Health Sciences, Dharan, Nepal.

Dr. Amit Agrawal, Assistant Professor in Neurosurgery, Department of Surgery, B.P. Koirala Institute of Health Sciences, Dharan, Nepal.
Extensive subgaleal hematoma rarely may occur several days after minor head trauma. This case illustrates the need to recognize this entity as well as manage it effectively.
Subgaleal hemorrhage, subgaleal hematoma, head injury
The subgaleal (subaponeurotic) space extends from the orbital ridges to the nape of the neck and laterally to the ears. In children massive hemorrhage may occur into this space and can result in hemodynamic instability. 1 We present a case of delayed extensive subgaleal hemorrhage in a child 6 weeks after minor head injury.
Case Report
This 11 years female child presented with history of fall while playing at school seven weeks back. At that time there was no history of loss of consciousness, vomiting, ENT bleed or convulsions. 10 days back she developed suddenly increasing scalp swelling that was increased for 1 day and stopped progressing since than. There was no history of repeat trauma. There was no history of bleeding disorders. Her general and systemic examination was normal. Neurological examination was normal. Local examination revealed extensive, non-tender, fluctuant scalp swelling (Figure-1).

Figure 1: Extensive subgaleal hemorrhage involving frontal, right temporal and parietal region and limited by suture lines

[There was no local rise of temperature. Bleeding time (3'.30'), clotting time (7'), prothrombin time (15 second; control-13 second) and APTT (32 second, control-28 second) were normal. INR was 1.17. X-ray skull was normal. CT scan head showed extensive subgaleal hematoma with evidence of recent bleed. There was no skull fracture or intracranial lesions.

Figure 2: Plain CT scan shows circumferential scalp hemorrhage crossing sutural boundaries. There is no intracranial lesion
Delayed extensive subgaleal hematoma is an uncommon, but dramatic complication of minor head trauma. 2 However in some patients' small subgaleal hematoma can increase in size in patients with coagulation disorders aggravated by the use of nonsteroidal anti-inflammatory drugs. 3 In our patient preliminary coagulation profile was normal and there was no history of drug intake. In cases where scalp swell­ing is massive, computed tomogra­phy or magnetic resonance imaging is required for evaluation of these patients. 4 Most hematomas spontaneously resolved within four weeks of the injury, so that masterly inactivity should be the first line of treatment for this entity. 2, 5 The major pitfalls in managing these patients are failure to recognize this entity and, particularly in the infant, failure to carefully assess the hemodynamic status. 2
Compliance with Ethical Standards
Funding None
Conflict of Interest None
  1. Kassner EG, Haller JO. Birth trauma: perinatal asphyxia and iatrogenic respiratory distress. In: Kassner EG, editor. Iatrogenic disorders of the fetus, infant and child. Volume I. New York : Springer Verlag, 1985:125-90.  [CrossRef]
  2. Cooling DS, Viccellio P. Massive subgaleal hematoma following minor head trauma. J Emerg Med. 1991;9 Suppl 1:33 -5.  [CrossRef]
  3. Pomeranz AJ, Ruttum MS, Harris GJ. Subgaleal hematoma with delayed proptosis and corneal ulceration. Ann Emerg Med. 1995;26(6):752-4.  [CrossRef]
  4. King S J, Boothroyd A E. Cranial trauma following birth in term infants. The British Journal of Radiology, 71 (1998), 233-238.  [CrossRef]  [PubMed]
  5. Adeloye A, Odeku EL. Subgaleal hematoma in head injuries. Int Surg. 1975;60(5):263-5.  [PubMed]

Cite this article as:
Agrawal A, Pratap A, Sundas A, Tiwari A. DELAYED EXTENSIVE SUBGALEAL HEMATOMA FOLLOWING MINOR HEAD INJURY. Pediatr Oncall J. 2006;3: 72.
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