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Cephalohematoma

By Sushila Ladumor, MD, FRCR | 15 de febrero de 2012

History: A 7-week-old female with left scalp hard swelling, rule outhematoma

Skull X-Ray: Frontal and lateral projection.

The skull radiograph demonstrates a rim of calcification in the periphery

Vol. No. February 15, 2012

http://www.diagnosticimaging.com/display/article/113619/2032567 1


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of a raised swelling on the left parietal bone. This finding ischaracteristic of a cephalohematoma in its healing stages.

The skull radiograph demonstrates a rim of calcification in the periphery of a raisedswelling on the parietal bone. This finding is characteristic of a cephalohematoma inits healing stages.

Definition

The cephalohematoma represents subperiosteal hemorrhage. The periosteum of the involved bone,usually parietal or occipital bone, is elevated by the underlying hematoma. Therefore, the hematoma issharply limited by the margins of the bone and does not cross suture lines. In its earliest stages (first twoweeks), the hematoma is of soft tissue density due to its blood contents. Early skull films (during thefirst two weeks) will show the swelling as a soft tissue "mass" which is limited at its margins by thecranial sutures.

As healing progresses, there is formation of a shell of bone by the elevated periosteum and thecalcification becomes visible radiographically, as in this case. It initially appears as a thin calcified shellat approximately two weeks, covering the hematoma, and the layer of calcification subsequentlythickens as it matures. The later sequelae, following complete resorption of hematoma, result inincorporation of the calcified rim into the outer table of the skull. This may persist for months or yearsas a palpable (and radiographically visible) thickening of the outer table of the skull.

Subtle skull fractures underlying the cephalohematoma may coexist but are usually not clinicallysignificant.




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Causes

The usual causes of a cephalohematoma are a prolonged second stage of labor or instrumental delivery,particularly ventouse.

Symptoms

If severe the child may develop jaundice, anemia or hypotension. In some cases it may be an indicationof a linear skull fracture or be at risk of an infection leading to osteomyelitis or meningitis.

The swelling of a cephalohematoma takes weeks to resolve as the blood clot is slowly absorbed from theperiphery towards the centre. In time the swelling hardens (calcification) leaving a relatively softercenter so that it appears as a depressed fracture.

Cephalohematoma should be distinguished from another scalp bleeding called subgaleal hemorrhage(also called subaponeurotic hemorrhage), which is blood between the scalp and skull bone (above theperiosteum) and is more extensive. It is more prone to complications, especially anemia and bruising.

Management

No laboratory studies usually are necessary. Vitamin C has been reported to hurry the resorption ofhematoma. Skull X-ray or CT scanning is used if neurological symptoms appear. Usual management ismainly observation. Transfusion and phototherapy may be necessary if blood accumulation issignificant. Aspiration is more likely to increase the risk of infection. The presence of a bleedingdisorder should be considered. Skull radiography or CT scanning is also used if concomitant depressedskull fracture is a possibility.

Differential Diagnosis

In the neonate, swelling of the scalp may also be seen with caput succedaneum (subcutaneous edema

and/or hemorrhage) and subgaleal hemorrhage (subaponeurotic hemorrhage). These two conditions aremore superficial and extend more widely over the skull because they are not limited by the attachmentsof the periosteum.

In the older infant and child, sequelae of cephalohematoma may cause confusion. Asymmetry of theskull or palpable bulge at the site of the calcified cephalohematoma may cause clinical concern for askull mass or craniosynostosis. Skull radiography will usually demonstrate the characteristic smooththickening resulting from an old calcified cephalohematoma. The findings may persist for years, eveninto adulthood. A cyst-like radiolucent lesion at the site of old cephalohematoma may also persist, andthis entity should be kept in mind when evaluating cyst-like skull lesions.

Sushila Ladumor, MD, FRCR, Consultant Radiologist with Multi-modality Imaging experience, working

in Medical Imaging Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia.

References:

http://www.pedsradiology.com/Historyanswer.aspx?qid=59&fid=1http://en.wikipedia.org/wiki/File:Scalp_hematomashttp://www.fpnotebook.com/nicu/neuro/Cphlhmtm.htm




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