Birth Head Trauma

Youmans chapter 212Avinash Mohan, Robin M. Bowman

3/06/59

Outline

• Incidence and risk factor• Scalp injury• Skull fractures• Intracranial hemorrhage

Incidence and risk factor• Fracture, paralysis, laceration• 1 and 11.7 per every 1000 to 2000 live birth• Perinatal death secondary to birth trauma : 1 in 1000 to

2000• Risk factor : macrosomia(> 4000 gms), growth

retardation, preterm labor, breech presentation, multiparity

• Mode of delivery– Vaginal delivery with forceps or vacuum extractor : higher rate of

trauma– Cesarean section : lower rate of birth trauma

Scalp injury

Caput succedaneum• Most common,normally at vertex• Superficial serosanguineous collection that crosses

suture lines• Edema of the outer layer of the scalp,collection in the

portion of the scalp that lead way down the birth canal• Associated with the use of vacuum extraction• Immediately after birth• Management

– Resolve in 24 hr

Subgaleal hematoma• Most life-threatening• Hemorrhage beneath aponeurosis of scalp that crosses

suture lines• Galea aponeurotica extend from the supra orbital rims to

the hairline posteriorly and laterally to the level of the ears potential space can easily accommodate the entire blood volume of neonate

• Risk for development– Coagulation defect– Vitamin K deficiency– Difficult delivery in which vacuum extraction is used

Subgaleal hematoma• Clinical diagnosis : identifying a fluctuant scalp mass that

extends beyond the cranial sutures and is more sizable than caput succedaneum

• Easily identified on CT• Management

– Emergency blood transfusion and coagulation factor

Cephalohematoma• 1-2% of all birth• Accumulation of blood between the periosteum and

bone,therefore the cranial sutures limit its expansion• Forces of labor acting on the neonatal head shear the

periosteum away from the bone• Most common location : parietal region• No clinical significant • Management

– Resolve spontaneously within a few weeks to month

Cephalohematoma• Complication :

– Infection, lead to osteomyelitis, meningitis or sepsis• Most common organiasm : E.Coli• Usually occurs within 3 wks• Rx : diasnostic tap or open irrigation and drainage

– Hyperbilirubinemia– Anemia– hemodynamic instability

Skull fracture• Cause : narrow pelvic passage or pressure against the

promontory of the sacrum by forceps and vacuum extractor

• CT for rule out an associated intracranial hemorrhage• 3 type

– Linear skull fracture– Depressed skull fractures– Occipital osteodiastasis

Linear skull fracture• 5-25%, associated with cephalohematoma• Most common : parietal bone• CT for rule out an EDH• Management

• Usually heal within 2 to 3 months• require only a follow-up skull radiograph to rule out a

growing skull fracture• Growing skull fracture(posttraumatic leptomeningeal cyst)

• Fracture lines that widening with time and dural tear• Cyst cause mass effect with neurological deficit

Depress or Ping-Pong skull fracture

• Unique to newborn period,because of thin,pliable nature of a newborn’s skull

• CT scan• Often improve and become elevated spontaneously• Indication for surgery

• bone fragement in the cerebrum• neurological deficit with or without increase intracranial pressure

• Management• Elevated by sliding a Penfield dissector• Care must be taken to completelt strip the dura away from the

suture line and under the fracture• Should not use intact skull for fulcrum

Depress or Ping-Pong skull fracture

Occipital osteodiastasis• Difficult delivery,forceps breech delivery• Synchondrosis opens between the squamous part and

the condylar portion of the occipital bone• Increase tentorial and falcine tears, with damage to

draining venous structures

Occipital osteodiastasis

Intracranial hemorrhage• Most serious complication• Initial symptoms related to mass effect,especially for

lesion in the posterior fossa• Perinatal seizure• CT imaging• Type

– Epidural hematoma– Subdural hematoma– Subarachnoid hemorrhage– Intraparenchymal hematoma

Epidural hematoma• Associated with skull fracture in 30-40% of case• Skull may distort without fracture,thereby tearing the

dura away from the under surface of cranium• Bleeding form emissary dural veins or from branch of

middle meningeal artery• May initially go undetected,until increase ICP• Sign of increase ICP

– Full fontanelle– Increase head circumference– Brainstem compression with pupillary changes

Epidural hematoma• Management

– Less than 1 cm thick : conservative with series CT– Open craniotomy with evacuation of the hematoma

Subdural hematoma• Secondary to rupture cortical vein• Excessive vertical molding of the head, elongation and

distortion of the head• Posterior fossa subdural hematoma(PFSH)

– Exhibit symptoms withing 24 hr after birth– Most common initial symptom : irritability, lethargy, a

full fontanelle, hypotonia, poor oral intake and unstable vital sign

– CT scan

Subdural hematoma– Management

• Aggressive drainage : cause sign of IICP or brain stem compression

• Difficult to gain access• Dissolve spontaneous time• Hydrocephalus,follow

Subdural hematoma

Intraparenchymal hemorrhage• Usually occur in conjunction with SDH• Due to mechanical deformation of the intraoccipital

synchondrosis during delivery when the lower lip of squamous portion of the occipital bone is depressed and cause cerebellar contusion or laceration

• Associated with forceps or breech delivery• Symptom similar to SDH• CT scan• Management

– Small clot : conservative– Large ones causing sign of brain or brain stem compression require

surgical evacuation

Thank you