Neonatal subgaleal hematoma causing brain compression: report of two cases and review of the literature

Neonatal subgaleal hematomas (SGHs) are infrequent but underdiagnosed collections of blood beneath the galea, often caused by vacuum delivery. With massive bleeding into the subgaleal space, exsanguination and hypovolemic shock can cause death in 20 to 60% of newborn infants. We report the first two known patients with extracranial cerebral compression caused by SGH. Also, the surgical evacuation of neonatal SGH has not been described previously. One patient was a full-term boy who was delivered via vacuum extraction after an uncomplicated pregnancy. Within a few hours, he developed an expanding fluid collection of the scalp and disseminated intravascular coagulation and shock requiring intubation, inotropic support, and blood transfusions. His head circumference grew from 33 cm at birth to 42 cm. He became progressively lethargic and developed posturing movements. Computed tomography of the head revealed a massive SGH causing gross overlapping of the cranial sutures and diffuse cerebral edema. The other patient was a full-term boy delivered via cesarean section after an unsuccessful attempt at vacuum extraction and forceps delivery. The initial head circumference was 34 cm. Within a few hours, he developed an expanding fluid collection of the scalp and became progressively lethargic with posturing. Magnetic resonance imaging of the head revealed a massive SGH with cranial compromise and diffuse cerebral edema. Both children had radiographic features indicative of elevated intracranial pressure as well as neurological decompensation. The first patient was taken to the operating room, and the hematoma was evacuated through a small scalp incision. Initially, approximately 150 ml of blood was removed, and a Jackson-Pratt drain diverted another 200 ml of blood during the next 2 days. The infant made a good recovery. In the second case, the patient remained too unstable for operative intervention and died. Extracranial cerebral compression represents another way by which neonatal SGH may jeopardize the infant's life. Management consists of measures to correct hypovolemic shock and disseminated intravascular coagulation, as well as surgical intervention to control elevated intracranial pressure.