Subgaleal hematoma

Subgaleal hematoma

Subgaleal hematoma is a type of cephalhematoma in the potential space between the periosteum and the galea aponeurosis.

They dont calcify.

Its occurrence beyond the neonatal period is rare and is often associated with head trauma involving tangential or radial forces applied to the scalp causing emissary veins traversing the subgaleal space to be ruptured 1).

In patients with traumatic intracranial hemorrhage or skull fractures, the incidence is increased.

In the newborn infant is rare, occurs early, and often bears serious consequences.

The diagnosis is generally a clinical one, with a fluctuant boggy mass developing over the scalp

Laboratory studies consist of a hematocrit evaluation.

Right frontotemporoparietal intracranial acute epidural hematoma, up to 1 cm. thick, underlying a broad line of right temporoparietal Right parietal subgaleal hematoma, up to 1cm. of thickness.

Hemorrhage under the scalp

Not to confuse with subperiosteal hematoma.


Small gyriform laminar hyperdensity is observed in the left superior frontal sulcus in relation to a small subarachnoid hemorrhage. Left parietal subgaleal hematoma up to 7 mm thick.

Although rare, rapid spontaneous resolution of epidural hematomas in the pediatric population has even been reported 2).

Numerous theories have been proposed to explain the pathophysiology behind these cases, including egress of epidural collections through cranial discontinuities (fractures/open sutures), blood that originates in the subgaleal space, and bleeding from the cranial diploic cavity after a skull fracture that preferentially expands into the subgaleal space 3)

Children born by use of vacuum extractor or forceps require careful monitoring by the nursing staff throughout their stay in the maternity unit 4).

In most cases, conservative treatment is the preferred option because adhesion between the galea aponeurotica and the periosteum restricts the extent of the hematoma. In special cases, however, the hematoma enlarges extraordinarily past these adhesions, and the patients thus affected suffer from progressive anemia followed by the lethargy and headache resulting from the excessive distension of the skin and the subcutaneous tissue. In such cases, hematoma removal is performed in order to relieve the symptoms 5).

The therapeutic strategy for massive subgaleal hematoma is individualized. However, treatment for massive subgaleal hematoma with skull fracture should not be considered the same as for hematoma without skull fracture. Emergent surgery is recommended before neurological deterioration is recognized in the patient if damage to the dural sinus is suspected 6).

Endoscopic techniques have been advanced along with the recent trend toward invasive neurosurgery. These minimally invasive techniques can allow sufficient removal of subgaleal hematoma with minimal morbidity, especially in patients such as ours. In addition, the utility of endoscopic techniques for the removal of subgaleal hematoma should be confirmed after long-term follow-up 7).

Usually starts as a small localized hematoma, and may become huge (with significant loss of circulating blood volume in age < 1 year, transfusion may be necessary).


A 3 kg baby was delivered by cesarean section after prolonged labor. He had massive subgaleal hematoma. He developed anemia requiring packed cell transfusions and hyperbilirubinemia requiring a total of seven exchange transfusions and highly intensive phototherapy. There were no adverse complications of the hyperbilirubinemia or the exchange transfusion 8).

A 39-year-old healthy worker came to our emergency department (ED) due to scalp lacerations from an accident that caused severe twisting of his hair. He denied head contusion and was conscious upon arrival. Physical examination showed three lacerations over his right temporal area. The wounds depth extended to the skull, with a 10-cm subperiosteal pocket beneath the lacerations. Primary sutures were performed immediately under local anesthesia, not only for wound closure but also for hemostasis. However, he returned to our ED 3 h after the first visit for a newly developed soft lump over the left side of his forehead. Computed tomography scan of brain illustrated a huge and diffuse SGH in the left temporal region with extension to periorbital region. Although the option of incision and drainage was discussed with a neurosurgeon and a search for some case reports was done, most of the hematoma could be self-limited. Conservative management with non-elastic bandage packing direct compression was applied. The patient was then admitted for close observation and conservative treatment for 1 week. There was no recurrence of SGH in the following 3 months. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: SGH is an uncommon phenomenon that is caused by tearing of the emissary veins in the loose areolar tissue located beneath the galeal aponeurosis. Conservative treatment with bandage compression is recommended for SGH. Surgery is reserved for cases where non-invasive management fails or severe complications 9).


1)

Vu TT, Guerrera MF, Hamburger EK, Klein BL. Subgaleal hematoma from hair braiding.Case report and literature review. Pediatr Emerg Cure. 2004;20:821–3
2)

Chida K, Yukawa H, Mase T, Endo H, Ogasawara K. Spontaneous slow drainage of epidural hematoma into the subgaleal space through a skull fracture in an infant–case report. Neurol Med Chir (Tokyo). 2011;51(12):854-6. PubMed PMID: 22198110.
3)

Tataryn Z, Botsford B, Riesenburger R, Kryzanski J, Hwang S. Spontaneous resolution of an acute epidural hematoma with normal intracranial pressure: case report and literature review. Childs Nerv Syst. 2013 Nov;29(11):2127-30. doi: 10.1007/s00381-013-2167-8. Epub 2013 May 26. Review. PubMed PMID: 23708934.
4)

Boumahni B, Ghazouani J, Bey KJ, Carbonnier M, Staquet P. [Subgaleal hematoma in 2 neonates]. Arch Pediatr. 2010 Oct;17(10):1451-4. doi: 10.1016/j.arcped.2010.07.011. Epub 2010 Sep 18. French. PubMed PMID: 20851581.
5)

Amar AP, Aryan HE, Meltzer HS, Levy ML. Neonatal subgaleal hematoma causing brain compression: Report of two cases and review of the literature. Neurosurgery. 2003;52:1470–4.
6)

Yamada SM, Tomita Y, Murakami H, Nakane M. Delayed post-traumatic large subgaleal hematoma caused by diastasis of rhomboid skull suture on the transverse sinus. Childs Nerv Syst. 2015 Apr;31(4):621-4. doi: 10.1007/s00381-014-2531-3. Epub 2014 Aug 21. PubMed PMID: 25142690.
7)

Hayashi Y, Kita D, Furuta T, Oishi M, Hamada J. Endoscopic removal of subgaleal hematoma in a 7-year-old patient treated with anticoagulant and antiplatelet agents. Surg Neurol Int. 2014 Jun 20;5:98. doi: 10.4103/2152-7806.134911. eCollection 2014. PubMed PMID: 25024898; PubMed Central PMCID: PMC4093743.
8)

Dutta S, Singh A, Narang A. Subgaleal hematoma and seven exchange transfusions. Indian Pediatr. 2004 Mar;41(3):267-70. PubMed PMID: 15064515.
9)

Chen CE, Liao ZZ, Lee YH, Liu CC, Tang CK, Chen YR. Subgaleal Hematoma at the Contralateral Side of Scalp Trauma in an Adult. J Emerg Med. 2017 Nov;53(5):e85-e88. doi: 10.1016/j.jemermed.2017.06.007. Epub 2017 Sep 20. PMID: 28941556.

Chronic subdural hematoma recurrence prevention

Chronic subdural hematoma recurrence prevention

In total, 402 studies were included in this analysis and 32 potential risk factors were evaluated. Among these, 21 were significantly associated with the postoperative recurrence of CSDH. Three risk factors (male, bilateral hematoma, and no drainage) had convincing evidence 1).

The single most important factor appears to be the residual subdural space after drainage of the chronic subdural hematoma and an effort should be made by the surgeon to facilitate the expansion of the underlying brain. The presence of a functioning drain for 48–72 h draining the subdural fluid and promoting brain expansion will reduce the subdural space, thus reducing the recurrence of the CSDH. Some of the relevant surgical nuances include placement of at least two burr holes with the burr holes located to drain multiple cavities, copious irrigation of the subdural space, placement of the drain in the dependent burr hole site, near-total filling of the subdural space with irrigation to prevent a pneumocephalus and placing a subdural drain. Closure of the site with a large piece of Gelfoam prevents the subgaleal blood to migrate into the subdural space.

Postoperative subdural drain of maximal 48 h is effective in reducing recurrent hematomas. However, the shortest possible drainage time without increasing the recurrence rate is unknown

see Subdural drain for chronic subdural hematoma

The effect of a physical property of irrigation solution (at body vs room temperature) on the chronic subdural hematoma recurrence rate needs further study.

Objective: To explore whether irrigation fluid temperature has an influence on cSDH recurrence.

Design, setting, and participants: This was a multicenter randomized clinical trial performed between March 16, 2016, and May 30, 2020. The follow-up period was 6 months. The study was conducted at 3 neurosurgical departments in Sweden. All patients older than 18 years undergoing cSDH evacuation during the study period were screened for eligibility in the study.

Interventions: The study participants were randomly assigned by 1:1 block randomization to the cSDH evacuation procedure with irrigation fluid at room temperature (RT group) or at body temperature (BT group).

Main outcomes and measures: The primary end point was recurrence requiring reoperation within 6 months. Secondary end points were mortality, health-related quality of life, and complication frequency.

Results: At 6 months after surgery, 541 patients (mean [SD] age, 75.8 [9.8] years; 395 men [73%]) had a complete follow-up according to protocol. There were 39 of 277 recurrences (14%) requiring reoperation in the RT group, compared with 16 of 264 recurrences (6%) in the BT group (odds ratio, 2.56; 95% CI, 1.38-4.66; P < .001). There were no significant differences in mortality, health-related quality of life, or complication frequency.

Conclusions and Relevance: In this study, irrigation at body temperature was superior to irrigation at room temperature in terms of fewer recurrences. This is a simple, safe, and readily available technique to optimize outcome in patients with cSDH. When irrigation is used in cSDH surgery, irrigation fluid at body temperature should be considered standard of care.

Trial registration: ClincalTrials.gov Identifier: NCT02757235 2).

A study aimed to evaluate the efficacy and safety of half-saline solution for irrigation in burr hole trephination for chronic subdural hematoma.

This randomized clinical trial was conducted in university hospital referral centers from 2020 to 2021. Sixty-three patients with chronic subdural hematoma eligible for burr hole trephination were primarily enrolled. Two patients were excluded because of concurrent stroke. Sixty-one patients were randomly allocated into case (HS=30) and control (normal-saline [NS]=31) groups. HS was used to irrigate the hematoma in the case group and NS was used in the control group. The patients were followed-up. Clinical variables including demographic and medical findings, postoperative computed tomography findings, postoperative complications, hospitalization period, recurrence rate, and functional status measured by the Barthel type B index were recorded.

Forty-six of 61 patients were male (75.4%), and the patients’ mean age was 65.4±16.9 years, with equal distribution between the 2 groups. Postoperative effusion and postoperative hospital stay duration were significantly lower in the HS group than in the NS group (p=0.002 and 0.033, respectively). The postoperative recurrence within 3 months in both groups was approximately equal (6.6%). In terms of functional outcomes and postoperative complications, HS showed similar results to those of NS.

Conclusion: HS as an irrigation fluid in BHC effectively reduced postoperative effusion and hospital stay duration without considerable complications.

Trial registration: Iranian Registry of Clinical Trials Identifier: IRCT20200608047688N1 3).


1)

Zhu F, Wang H, Li W, Han S, Yuan J, Zhang C, Li Z, Fan G, Liu X, Nie M, Bie L. Factors correlated with the postoperative recurrence of chronic subdural hematoma: An umbrella study of systematic reviews and meta-analyses. EClinicalMedicine. 2021 Dec 20;43:101234. doi: 10.1016/j.eclinm.2021.101234. PMID: 34988412; PMCID: PMC8703229.
2)

Bartley A, Bartek J Jr, Jakola AS, Sundblom J, Fält M, Förander P, Marklund N, Tisell M. Effect of Irrigation Fluid Temperature on Recurrence in the Evacuation of Chronic Subdural Hematoma: A Randomized Clinical Trial. JAMA Neurol. 2022 Nov 21. doi: 10.1001/jamaneurol.2022.4133. Epub ahead of print. PMID: 36409480.
3)

Mahmoodkhani M, Sharafi M, Sourani A, Tehrani DS. Half-Saline Versus Normal-Saline as Irrigation Solutions in Burr Hole Craniostomy to Treat Chronic Subdural Hematomata: A Randomized Clinical Trial. Korean J Neurotrauma. 2022 Sep 29;18(2):221-229. doi: 10.13004/kjnt.2022.18.e47. PMID: 36381457; PMCID: PMC9634318.

Pediatric Emergency Care Applied Research Network (PECARN)

Pediatric Emergency Care Applied Research Network (PECARN)

see PECARN traumatic brain injury algorithm.

The overuse of CT leads to inefficient care. Therefore, to maximize precision and minimize the overuse of CT, the Pediatric Emergency Care Applied Research Network (PECARN) previously derived clinical prediction rules for identifying children at high risk and very low risk for intra-abdominal trauma undergoing acute intervention and clinically important traumatic brain injury after blunt trauma in large cohorts of children who are injured.

A study aimed to validate the IAI and age-based TBI clinical prediction rules for identifying children at high risk and very low risk for IAIs undergoing acute intervention and clinically important TBIs after blunt trauma.

This was a prospective 6-center observational study of children aged <18 years with the blunt torso or head trauma. Consistent with the original derivation studies, enrolled children underwent a routine history and physical examinations, and the treating clinicians completed case report forms prior to knowledge of CT results (if performed). Medical records were reviewed to determine clinical courses and outcomes for all patients, and for those who were discharged from the emergency department, a follow-up survey via a telephone call or SMS text message was performed to identify any patients with missed IAIs or TBIs. The primary outcomes were IAI undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion, or intravenous fluid for ≥2 days for pancreatic or gastrointestinal injuries) and clinically important TBI (death from TBI, neurosurgical procedure, intubation for >24 hours for TBI, or hospital admission of ≥2 nights due to a TBI on CT). Prediction rule accuracy was assessed by measuring rule classification performance, using a standard point and 95% CI estimates of the operational characteristics of each prediction rule (sensitivity, specificity, positive and negative predictive values, and diagnostic likelihood ratios).

The project was funded in 2016, and enrollment was completed on September 1, 2021. Data analyses are expected to be completed by December 2022, and the primary study results are expected to be submitted for publication in 2023.

This study will attempt to validate previously derived clinical prediction rules to accurately identify children at high and very low risk for clinically important intra-abdominal trauma and traumatic brain injury. Assuming successful validation, widespread implementation is then indicated, which will optimize the care of children who are injured by better aligning CT use with need.

International registered report identifier (irrid): RR1-10.2196/43027 1).

Blunt head trauma is common in children and a common reason for presentation to an emergency department. Head CT involves radiation exposure and the risk of fatal radiation-related malignancy increases with younger age at CT 2). The PECARN flow diagram flags assessment features that increase the risk of ci-TBI and weigh them against the risk of radiation exposure. Therefore, it is useful in avoiding unnecessary radiation exposure in younger patients, where it is safe to do so, and identifying those at risk that require further investigation.

In PECARN, altered mental status was defined as GCS 14 or agitation, somnolence, repetitive questioning, or slow response to verbal communication.

Severe mechanisms of injuries including:

motor vehicle crash with patient ejection

death of another passenger, or rollover

pedestrian or bicyclist without helmet struck by a motorized vehicle falls

more than 1.5 m (5 feet) for patients aged 2 years and older

more than 0.9 m (3 feet) for those younger than 2 years

head struck by a high-impact object

The algorithm was created from patients presenting to an emergency department within 24 hours of the trauma and with blunt trauma only.

Excluded criteria included:

penetrating trauma

known brain tumors

pre-existing neurological disorders complicating assessment

neuroimaging at a hospital outside before transfer

and therefore may not apply to patients with these features.

TBI on CT was defined as any of:

intracranial hemorrhage or contusion

cerebral edema

traumatic infarction

diffuse axonal injury

shearing injury

sigmoid sinus thrombosis

midline shift of intracranial contents or signs of brain herniation

diastasis of the skull

pneumocephalus

skull fracture depressed by at least the width of the table of the skull


Kuppermann et al. analyzed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp hematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0) and sensitivity of 25/25 (100%, 86.3-100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99.95%, 99.81-99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations.

These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated 3).


A study applied two different machine learning (ML) models to diagnose mTBI in a paediatric population collected as part of the paediatric emergency care applied research network (PECARN) study between 2004 and 2006. The models were conducted using 15,271 patients under the age of 18 years with mTBI and had a head CT report. In the conventional model, random forest (RF) ranked the features to reduce data dimensionality and the top ranked features were used to train a shallow artificial neural network (ANN) model. In the second model, a deep ANN applied to classify positive and negative mTBI patients using the entirety of the features available. The dataset was divided into two subsets: 80% for training and 20% for testing using five-fold cross-validation. Accuracy, sensitivity, precision, and specificity were calculated by comparing the model’s prediction outcome to the actual diagnosis for each patient. RF ranked ten clinical demographic features and twelve CT-findings; the hybrid RF-ANN model achieved an average specificity of 99.96%, sensitivity of 95.98%, precision of 99.25%, and accuracy of 99.74% in identifying positive mTBI from negative mTBI subjects. The deep ANN proved its ability to carry out the task efficiently with an average specificity of 99.9%, sensitivity of 99.2%, precision of 99.9%, and accuracy of 99.9%. The performance of the two proposed models demonstrated the feasibility of using ANN to diagnose mTBI in a paediatric population. This is the first study to investigate deep ANN in a paediatric cohort with mTBI using clinical and non-imaging data and diagnose mTBI with balanced sensitivity and specificity using shallow and deep ML models. This method, if validated, would have the potential to reduce the burden of TBI evaluation in EDs and aide clinicians in the decision-making process 4).


1)

Ugalde IT, Chaudhari PP, Badawy M, Ishimine P, McCarten-Gibbs KA, Yen K, Atigapramoj NS, Sage A, Nielsen D, Adelson PD, Upperman J, Tancredi D, Kuppermann N, Holmes JF. Validation of Prediction Rules for Computed Tomography Use in Children With Blunt Abdominal or Blunt Head TraumaProtocol for a Prospective Multicenter Observational Cohort Study. JMIR Res Protoc. 2022 Nov 24;11(11):e43027. doi: 10.2196/43027. PMID: 36422920.
2)

Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol. 2001 Feb;176(2):289-96.
3)

Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70. doi: 10.1016/S0140-6736(09)61558-0. Epub 2009 Sep 14. Erratum in: Lancet. 2014 Jan 25;383(9914):308. PMID: 19758692.
4)

Ellethy H, Chandra SS, Nasrallah FA. The detection of mild traumatic brain injury in paediatrics using artificial neural networks. Comput Biol Med. 2021 Aug;135:104614. doi: 10.1016/j.compbiomed.2021.104614. Epub 2021 Jun 30. PMID: 34229143.
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