Diagnose this 2-month-old with scalp swelling | Image Credit: © daqota - © daqota - stock.adobe.com.
Subgaleal hemorrhage refers to the accumulation of blood between the periosteum of the skill and the aponeurosis.1 This type of soft tissue injury of the scalp in infants is often caused by shearing forces during vacuum or forceps delivery.2 It is a rare and potentially fatal condition in newborns, with risk of severe complications such as hypovolemic shock, coagulopathy, acute anemia, and even death, requiring early detection.1,3 Existing research indicates that subgaleal hemorrhage typically presents within the first 48 hours, most commonly occurring within the initial eight hours post-birth.4 However, this case report discusses a rare occurrence of delayed presentation of subgaleal hemorrhage in an otherwise normally developing 2-month-old female. Literature contains very few case reports addressing such delayed instances of subgaleal hemorrhage.3,4 This report highlights the need for timely diagnosis and treatment of subgaleal hemorrhage beyond the neonatal period by pediatricians and emergency department doctors due to its potential life-threatening nature and unique presentation.
A 2-month-old female was born after an uneventful pregnancy at 40 weeks’ gestation via vacuum-assisted vaginal delivery to a G2P1011 female. The patient’s APGAR scores were 7 and 9 at 1 and 5 minutes, respectively, at birth. No bleeding or other complications were reported during delivery. The newborn and mother were discharged two days after delivery without requiring NICU stay or interventions. The infant briefly developed a small soft palpable scalp swelling that resolved within days after delivery. The patient followed an otherwise uncomplicated growth progression since birth. She did exhibit mild reflux symptoms, which were managed with supportive care measures. Physical examination after delivery and subsequent exams revealed no abnormalities, including no signs of scalp swelling or injury.
At 8 weeks of age, the patient presented to the Emergency Department with a three-day history of new-onset scalp swelling. The parents decided to seek medical attention after the swelling became noticeably enlarged. Parents denied any changes in her mental status, vomiting, fevers, lethargy, irritability, or any other new concerns. She did have symptoms of gassiness and fussiness that were unchanged from baseline. No history of trauma was reported, and there were no concerning signs suggestive of nonaccidental trauma. The patient appeared well, with a soft, fluctuant palpable subcutaneous fluid collection overlying the parieto-occipital scalp, without crossing suture lines. The anterior fontanelle was soft and non-bulging, and there was no hemotympanum. The patient was initially diagnosed with cephalohematoma, thought to be related to the history of a vacuum-assisted delivery. At the time, head CT was discussed; however, it was thought mutually unnecessary given the patient's stable and otherwise asymptomatic condition. The patient was advised to follow up with her primary pediatrician.
Two days later, the patient was brought to the pediatrician’s office due to the increasing size of the swelling, with no other symptoms developing. The patient was referred for an outpatient urgent head ultrasound to evaluate for subgaleal vs other intracranial hemorrhage. However, due to delayed ultrasound availability, she was referred to the Emergency Department (ED) for urgent imaging.
In the ED, CT of the head was performed, which revealed subgaleal hemorrhage. The patient was admitted to the general pediatric floor for monitoring and further workup. Neurosurgery consultation was undertaken, with recommendations made for close observation with no immediate need for surgical intervention. A spine ultrasound was recommended due to a noted sacral hair tuft as well.
Hematology was consulted to evaluate for an underlying bleeding disorder due to delayed presentation with no apparent trauma. Initial workup performed during hospital stay revealed normal platelet count, normal PT of 10.5 seconds, normal PTT of 28.5 seconds, normal fibrinogen of 204, normal VWD panel of 105% VWF activity, 143% VWF ag, FVIII 108%, and normal VWF act/ag ratio of 0.7. Functional FXIII of 104% was also normal. Stable hemoglobin levels (>7mg/dL) throughout the admission precluded the need for blood transfusion.
She remained clinically stable during admission with regular neuro checks and close head circumference measurements. Upon discharge, parents were advised to follow up with hematology and neurosurgery as well as their primary care provider.
The patient has been cleared by the outpatient neurosurgical team as there were no concerns regarding increased intracranial pressure or the progression of the hematoma. Additionally, a spine ultrasound showed no evidence of spinal cord tethering. It is of note that on subsequent visits, the swelling was thought to in fact represent cephalohematoma vs subgaleal hematoma, with cephalohematoma thought more likely.
Comprehensive bleeding disorder workup by the outpatient hematology team has remained negative, with only a repeat Von Willebrand disease (VWD)panel pending. There is a presumption of an increased risk of bleeding, and it is acknowledged that the patient may require surgery or invasive procedures if symptomatic or not resolving, although this is thought unlikely. However, close monitoring is deemed essential for ongoing assessment of potential bleeding risks. (Table)
Table. Differential Diagnosis
Subgaleal hemorrhage is a life-threatening condition, which usually presents immediately after birth, most often following a vacuum or forceps assisted delivery. This report discusses an atypical case of delayed presentation subgaleal hemorrhage (vs cephalohematoma) in a 2-month-old female. It highlights the importance of recognizing and appropriately managing subgaleal hematomas in infants, including in the event of a delayed presentation.
The patient discussed in this report did not present with scalp swelling until 2 months of age. Despite remaining stable throughout the course of her life and hospitalization, the patient continues to carry an increased presumed risk of bleeding. Therefore, collaboration among pediatricians, emergency physicians, neurosurgeons, and hematologists/oncologists is crucial for a comprehensive assessment and appropriate follow-up care for addressing the complexities of delayed-onsetsubgaleal hematomas.
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