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.

Subgaleal abscess

Subgaleal abscess

Subgaleal abscesses and skull osteomyelitis are rarely encountered today.

The subgaleal space is the between the galea aponeurotica and periosteum of the cranial bones, subgaleal abscess may result from hematogenous infection or contiguous spread, and the diagnosis may not be initially obvious. The predominant organism isolated from post-traumatic and post-surgical scalp infections is Staphylococcus aureus.

Diagnosis and management will be guided by head CT scan, management of subgaleal abscess should focus on effective intravenous antibiotic therapy, immediate surgical drainage of abscess and debridement of necrotic tissue.

Subgaleal abscess is a rare complication, imaging can prevent serious complications. Negative pressure wound therapy is an invaluable tool for closure of the wounds 1).

Etiology

Reports of these entities usually describe an underlying pathology such as trauma or puncture wounds which account for direct inoculation or contiguous spread of microorganisms.

Acute bacterial sinusitis 2) Surgical correction of craniosynostosis 3)

Treatment

Although the diagnosis and management of a secondary subgaleal abscess may be straightforward, the same cannot be said for a primary or de novo subgaleal abscess 4).

Case series

Goodman SJ, Cahan L, Chow AW. Subgaleal abscess: a preventable complication of scalp trauma. West J Med. 1977 Aug;127(2):169-72. PubMed PMID: 898950; PubMed Central PMCID: PMC1237748.

Case reports

A case of extensive subgaleal abscess that presented as an infected scalp sebaceous cyst, in male diabetic patient, its management and the role of vaccum assisted closure (V.A.C.) dressing which was never described in such atypical presentation 5)


Spontaneous subgaleal abscess associated with lung adenocarcinoma: first description of this unusual association 6).


Spontaneous skull osteomyelitis with subgaleal abscess due to Kocuria rosea 7).


A 47-year-old immunosuppressed woman presented with fever, altered level of consciousness, dysphasia, and a left occipital subgaleal fluctuant mass after acupuncture for headaches in the same area. Imaging demonstrated subgaleal and epidural collection localized in the left occipital region. She underwent urgent surgical evacuation of both collections. Cultures from intraoperative specimens grew Streptococcus anginosus. The patient started targeted antibiotic treatment leading to complete recovery.

This is the first report of intracranial abscess after acupuncture. Given the worldwide application of this alternative treatment, physicians, acupuncturists, and the general public should be aware of the possibility of this rare but serious complication 8).


A case of a 64-year-old Sri Lankan Sinhalese man with prolonged fever and constitutional symptoms with a neglected swelling over the back of the scalp who was found to have an abscess in the subgaleal space of the scalp during surgical drainage. Burkholderia pseudomallei was isolated in pus culture, and melioidosis serology was highly positive. The patient was treated with ceftazidime for 2 weeks, followed by co-trimoxazole for another 3 months. He made a complete clinical recovery with normalization of inflammatory markers. This is the first case of subgaleal abscess following melioidosis infection reported in the literature.

Abscesses in anatomically unusual locations should raise suspicion for melioidosis infection, particularly among patients with risk factors such as diabetes mellitus 9).


A case of an infected SGH in an 8-month-old following closed skull fracture. The patient presented with scalp swelling 1 day after falling 3 feet. Initial evaluation found a nondisplaced skull fracture on computed tomography. She was discharged following an uneventful 23-hour observation. Three days later, she developed symptoms concerning for a viral upper respiratory tract infection and received symptomatic treatment. Nine days after injury, she returned with continued fevers, irritability, and significant increase in scalp swelling. Magnetic resonance imaging showed a subgaleal abscess with osteomyelitis. Needle aspiration revealed an infected hematoma with cultures positive for Streptococcus pneumoniae, treated with intravenous ampicillin. Purulent drainage from an enlarging necrotic needle aspiration site required subsequent surgical debridement of the subgaleal abscess with drain placement. She recovered well following surgery and intravenous antibiotics. Physicians should be aware that SGH carries a risk of serious morbidity and mortality. SGH can serve as a nidus for infection, typically from skin barrier breakdown or, as in this case, hematogenous spread. Early recognition, appropriate antibiotic therapy, and surgical debridement are critical in treating infected SGH 10).


Chang et al. reported an infected SGH with abscess formation as a complication of early-onset Escherichia coli sepsis in a term neonate. The patient was discovered to have SGH soon after birth. Early-onset E. coli sepsis developed on Day 3 of life. The SGH became infected, with abscess formation 1 week later. The infected SGH was probably due to direct hematogenous spreading of sepsis. The patient was successfully treated without complications. Clinicians should be aware that SGH is a potential site of infection and infection may be caused either by direct hematogenous extension or from traumatic scalp lesions. Appropriate antibiotic treatment and surgical debridement are necessary when an infected SGH occurs 11).


Chou et al. reported on an elderly female who suffered from forehead carbuncle with intractable headache, later confirmed as having subgaleal abscess. Physicians should pay special attention to elderly and immune-compromised patients with carbuncles located in the middle of the face, especially when accompanied by intractable headache, to avoid poor outcome 12).


A 14-year-old boy with a rare combination of periorbital cellulitis, subgaleal abscess and superior sagittal sinus thrombosis following a late presentation of unilateral frontal sinusitis.

Following multiple surgical procedures, and antimicrobial and anticoagulation therapy, the patient made a full recovery.

Serious sinusitis complications still occur and can do so in unusual combinations with minimal clinical signs. Systemic anticoagulation therapy is considered safe practice in the management of cerebral venous sinus thrombosis and may reduce morbidity and mortality 13).


A 5-year-old child presented to the emergency department with a three-week history of fever associated with drowsiness and left parietal headache, and a week’s history of swelling on the left frontoparietal soft tissue. He had suffered a penetrating scalp injury four month ago. On physical examination, there was a tender swelling with purulent stream on the lateral half of his scalp. His vital signs are within normal limits. Plain X-ray of the skull showed a lytic lesion on the left frontoparietal bone. A cranial computed tomography (CT) scan demonstrated a large subgaleal abscess at the left frontoparietal region. SBO possesses a high morbidity and mortality; therefore, prompt diagnosis and appropriate treatment are mandatory to prevent further complications and to reduce morbidity and mortality significantly 14).


A case of bacterial meningitis, subgaleal, subdural, and epidural empyema due to Pasteurella multocida by a rabbit licking that resulted in neurological complications and a prolonged recovery period 15).


A preterm infant who developed scalp abscess and E. coli sepsis following a scalp electrode. Onyeama et al. recommend a careful examination of babies with a history of fetal electrode monitoring as this could be a nidus for local and generalised infection 16).


A 12-year-old girl presented with a swollen right eye with three days of pain and a diffused swollen frontal region and head lasting for one day. On the computed tomography with contrast, diffused collection was detected in the subgaleal regions and subperiosteal of the right orbita. It was observed that she had bilateral maxillary, ethmoidal, and frontal sinusitis and an infected bilateral middle concha bullosa in the right side. No symptoms of intracranial complication and osteomyelitis in the frontal or other calvarial bones were determined. This case presentation is thought to be the first one in literature that is an acute sinusitis without an intracranial complication and osteomyelitis, but with a diffused subgaleal abscess resulting from a subperiosteal abscess 17).

References

1) , 5)

Nabri M, Alharbi M, Al-Sayyid A, Alabdrabalrasol K, Hassan K, Al-Jehani H. Sub-galeal abscess: A rare sequel of an infected scalp sebaceous cyst. Int J Surg Case Rep. 2020 Sep 24;76:30-32. doi: 10.1016/j.ijscr.2020.09.063. Epub ahead of print. PMID: 33010610.
2)

Stokken J, Gupta A, Krakovitz P, Anne S. Rhinosinusitis in children: a comparison of patients requiring surgery for acute complications versus chronic disease. Am J Otolaryngol. 2014 Sep-Oct;35(5):641-6. doi: 10.1016/j.amjoto.2014.05.008. Epub 2014 Jun 5. PubMed PMID: 25069389.
3)

Zakhary GM, Montes DM, Woerner JE, Notarianni C, Ghali GE. Surgical correction of craniosynostosis. A review of 100 cases. J Craniomaxillofac Surg. 2014 Dec;42(8):1684-91. doi: 10.1016/j.jcms.2014.05.014. Epub 2014 Jun 4. PubMed PMID: 24969768.
4)

Schaefer J, Clein L, Conly J. De novo subgaleal abscess. Can J Infect Dis. 1992 Jan;3(1):30-2. PubMed PMID: 22451760; PubMed Central PMCID: PMC3307424.
6)

Umana GE, Scalia G, Fagone S, Strano G, Tranchina MG, Raudino G, Cicero S. Spontaneous subgaleal abscess associated with lung adenocarcinoma: first description of this unusual association. World Neurosurg. 2019 Aug 7. pii: S1878-8750(19)32149-7. doi: 10.1016/j.wneu.2019.07.233. [Epub ahead of print] PubMed PMID: 31400523.
7)

Rangnekar RD, Jamaluddin MA, Raja K, Abraham M. Spontaneous skull osteomyelitis with subgaleal abscess due to Kocuria rosea. Neurol India. 2019 May-Jun;67(3):915-918. doi: 10.4103/0028-3886.263238. PubMed PMID: 31347589.
8)

Priola SM, Moghaddamjou A, Ku JC, Taslimi S, Yang VXD. Acupuncture-Induced Cranial Epidural Abscess: Case Report and Review of the Literature. World Neurosurg. 2019 Feb 8. pii: S1878-8750(19)30300-6. doi: 10.1016/j.wneu.2019.01.189. [Epub ahead of print] PubMed PMID: 30743042.
9)

Dalugama C, Tennegedara A, Gawarammana IB. De novo subgaleal abscess – a rare presentation of melioidosis: a case report. J Med Case Rep. 2018 Apr 30;12(1):115. doi: 10.1186/s13256-018-1643-x. PubMed PMID: 29706135; PubMed Central PMCID: PMC5925829.
10)

Barry J, Fridley J, Sayama C, Lam S. Infected Subgaleal Hematoma Following Blunt Head Trauma in a Child: Case Report and Review of the Literature. Pediatr Neurosurg. 2015;50(4):223-8. doi: 10.1159/000433442. Epub 2015 Jun 13. Review. PubMed PMID: 26088299.
11)

Chang HY, Cheng KS, Liu YP, Hung HF, Fu HW. Neonatal infected subgaleal hematoma: an unusual complication of early-onset E. coli sepsis. Pediatr Neonatol. 2015 Apr;56(2):126-8. doi: 10.1016/j.pedneo.2013.03.003. Epub 2013 Apr 13. PubMed PMID: 23597516.
12)

Chou PY, Chen YC, Huang P. Forehead carbuncle with intractable headache. Neuropsychiatr Dis Treat. 2015 Mar 20;11:793-5. doi: 10.2147/NDT.S79349. eCollection 2015. PubMed PMID: 25848276; PubMed Central PMCID: PMC4376302.
13)

Jones H, Trinidade A, Jaberoo MC, Lyons M. Periorbital cellulitis, subgaleal abscess and superior sagittal sinus thrombosis: a rare combination of complications arising from unilateral frontal sinusitis. J Laryngol Otol. 2012 Dec;126(12):1281-3. doi: 10.1017/S0022215112002228. Epub 2012 Oct 1. PubMed PMID: 23020898.
14)

Sayhan MB, Kavalci C, Sogüt O, Sezenler E. Skull base osteomyelitis in the emergency department: a case report. Emerg Med Int. 2011;2011:947327. doi: 10.1155/2011/947327. Epub 2011 May 29. PubMed PMID: 22046552; PubMed Central PMCID: PMC3200088.
15)

Per H, Kumandaş S, Gümüş H, Oztürk MK, Coşkun A. Meningitis and subgaleal, subdural, epidural empyema due to Pasteurella multocida. J Emerg Med. 2010 Jul;39(1):35-8. doi: 10.1016/j.jemermed.2008.04.008. Epub 2008 May 16. PubMed PMID: 18486411.
16)

Onyeama CO, Srinivasan H, Lotke M, Vickers DL. Subgaleal abscess and E. coli septicemia following scalp electrode in a preterm newborn: a case report. J Matern Fetal Neonatal Med. 2009 Dec;22(12):1201-3. doi: 10.3109/14767050903042553. PubMed PMID: 19916718.
17)

Celik H, Islam A, Felek SA, Yüksel D. A very rare complication of acute sinusitis: subgaleal abscess. Kulak Burun Bogaz Ihtis Derg. 2009 May-Jun;19(3):155-8. PubMed PMID: 19857195.

Subgaleal drain for chronic subdural hematoma

Subgaleal drain for chronic subdural hematoma

Subgaleal drainage system is relatively less invasive, safe, and technically easy. So it is applicable for aged and higher risk patients 1).

Subgaleal suction drain was found to be an effective and safe method in the study of Yadav et al., for chronic subdural hematoma surgery 2).

It significantly reduced the incidence of recurrence. Similar observations were made in the study of Gazzeri et al. 3)

They placed the tip of suction drain on burr hole which can assist in continuous evacuation of hematoma or collected air.

Yadav et al., placed suction tip away from burr hole site which could avoid accidental slippage of tip in subdural space. Subgaleal drainage could avoid the risk of an acute hemorrhage from neo membrane injury which may occur during introduction and the removal of a subdural drain. It also reduces chances of brain parenchymal injury especially after suction drain 4).

A major complication of intracerebral hemorrhage could be due to a blind placement of the subdural drain.

There is a report of one acute SDH after subgaleal drain 5).

The subgaleal drain reduced the chances of significant pneumocephalus in the study of Yadav et al. 6).

The placement of subgaleal suction catheter could prevent the collection of subdural air, thus minimizing the risk of recurrence 7).

Postoperative infection in the subgaleal space has also been reported after subgaleal drainage 8).


A total of 763 patients with surgically evacuated unilateral CSDH were included for analysis. The recurrence rate was 14% while 12% of patients died during follow-up (1 year). In a association model, hematoma size, drain type, drainage time, presence of complications, and Glasgow Coma Score were significantly associated to recurrence. Subdural drain was associated with a lower recurrence risk than subgaleal drain. The preoperative model included hematoma size, hematoma density, and history of hypertension. The postoperative model included further drain type, drainage time, and surgical complications.

The nomograms allow easy assessment of the recurrence risk for the individual patient, providing a better possibility for individual adjustment of treatment and follow-up. The predictive performance indicates that significant unaccounted or unknown factors still remain. The association test found passive subdural drain superior to passive subgaleal drain in minimizing the risk of CSDH recurrence 9).

References

1)

Oral S, Borklu RE, Kucuk A, Ulutabanca H, Selcuklu A. Comparison of subgaleal and subdural closed drainage system in the surgical treatment of chronic subdural hematoma. North Clin Istanb. 2015 Sep 26;2(2):115-121. doi: 10.14744/nci.2015.06977. eCollection 2015. PubMed PMID: 28058351; PubMed Central PMCID: PMC5175088.
2) , 6)

Yadav YR, Parihar V, Chourasia ID, Bajaj J, Namdev H. The role of subgaleal suction drain placement in chronic subdural hematoma evacuation. Asian J Neurosurg. 2016 Jul-Sep;11(3):214-8. doi: 10.4103/1793-5482.145096. PubMed PMID: 27366247; PubMed Central PMCID: PMC4849289.
3) , 5) , 7) , 8)

Gazzeri R, Galarza M, Neroni M, Canova A, Refice GM, Esposito S. Continuous subgaleal suction drainage for the treatment of chronic subdural haematoma. Acta Neurochir (Wien). 2007;149(5):487-93; discussion 493. Epub 2007 Mar 28. PubMed PMID: 17387427.
4)

Choudhury AR. Avoidable factors that contribute to complications in the surgical treatment of chronic subdural haematoma. Acta Neurochir (Wien). 1994;129(1-2):15-9. PubMed PMID: 7998490.
9)

Andersen-Ranberg NC, Debrabant B, Poulsen FR, Bergholt B, Hundsholt T, Fugleholm K. The Danish chronic subdural hematoma study-predicting recurrence of chronic subdural hematoma. Acta Neurochir (Wien). 2019 May;161(5):885-894. doi: 10.1007/s00701-019-03858-9. Epub 2019 Mar 26. PubMed PMID: 30915574.