Definition

A subgaleal hematoma is a collection of blood between the galeal aponeurosis of the scalp and the periosteum of the skull. This potential space can extend to the orbital region (near the eyes), the occipital region (back of the head), and the temporal region (sides of the head). Injury to the blood vessels in the head can cause bleeding into the subgaleal space, which is considered the cause of subgaleal hematoma formation.

Bleeding in the subgaleal space is a rare but potentially fatal condition found in newborns. The prevalence of moderate to severe subgaleal bleeding at birth is about 1.5 per 10,000 births. Most diagnoses of subgaleal hematoma occur due to injuries from vacuum or forceps delivery. Subgaleal hematoma is often mistaken for conditions such as caput succedaneum and cephalohematoma.

Caput succedaneum is caused by swelling of the skin and subcutaneous tissue of the head. This condition typically resolves on its own within six days. Cephalohematoma is a condition where bleeding occurs under the baby's scalp (specifically between the bone and the periosteum layer of the skull) that does not cross the midline (suture) of the baby's head. This bleeding initially feels soft but will harden or calcify and can improve in about four months.

In contrast to subgaleal hematoma, caput succedaneum and cephalohematoma are generally not dangerous and typically resolve spontaneously. In some cases, caput succedaneum, cephalohematoma, and subgaleal hematoma can occur simultaneously. However, severe bleeding in the subgaleal space sometimes requires immediate blood transfusion and surgical evacuation. High-resolution head sonography can be performed as an initial examination, followed by a CT scan and MRI. Early diagnosis and appropriate therapy are crucial, as most cases with proper treatment will have good outcomes.

Causes

The cause of subgaleal hematoma is 90% due to vacuum extraction to the head during delivery. The vacuum can cause rupture of the blood vessels in the head (i.e., the connection between the dural sinus and scalp veins) and accumulation of blood in the galeal aponeurosis and periosteum of the scalp. Forty percent of subgaleal hematomas are caused by head injuries, such as intracranial bleeding or skull fractures.

Subgaleal hematoma occurs due to the rupture of venous vessels called emissary veins, which pass through the skull holes and drain blood from the cerebral sinus to the vessels outside the skull. Subgaleal bleeding is often associated with intracranial bleeding and/or cephalohematoma.

Risk Factor

The risk factors for subgaleal hematoma consist of two categories:

• Maternal factors. Premature rupture of membranes (PROM) > 12 hours and maternal exhaustion during labor.
• Infant factors. Macrosomia (large baby), neonatal coagulopathy (vitamin K deficiency, factor VIII and IX deficiency), low birth weight, male gender (2:1 to 8:1), low APGAR score (< 8 at 5 minutes), and fetal malpresentation.

Symptoms

Symptoms of subgaleal hematoma include:

• Blood under the galeal aponeurosis
• Swelling of the scalp, especially in the occipital region, which may be accompanied by bruising on the skin. Swelling appears gradually over 12-72 hours after delivery or may be immediately visible in severe cases.
• Periorbital ecchymosis (panda eyes) extending to the periorbital region (around the eyes) and neck
• Seizures
• Hypovolemic shock due to blood loss into the space between the periosteum of the skull and the galeal aponeurosis

Subgaleal hematoma can spread unnoticed, as it can spread through the calvaria and remain undetected for several hours to days. Patients with subgaleal hematoma may also experience hyperbilirubinemia (increased bilirubin levels) due to the absorption of hemolyzed (broken down) blood, followed by a decrease in hemoglobin and hematocrit due to significant blood loss into the subgaleal space.

Diagnosis

The diagnosis of subgaleal hematoma is usually based on clinical signs such as a soft lump on the scalp (especially in the occipital region). This lump appears gradually within 12-72 hours after delivery. However, in severe cases, it can occur immediately after birth. Subgaleal hematoma appears slowly and can sometimes go unnoticed for several hours. Supporting examinations to help establish the diagnosis include:

• Complete blood count showing a significant increase in bilirubin levels and decreased hematocrit.
• CT scan and MRI to determine the location and size of the subgaleal hematoma.

Management

Children born using a vacuum or forceps require close monitoring in the care unit. Monitoring includes measuring head circumference, assessing vital signs, and checking for signs of shock. In most cases, conservative treatment is preferred. The hematoma may expand and cause progressive anemia (blood deficiency) accompanied by fatigue and headache. In such cases, hematoma removal is performed to relieve symptoms.

Treatment for extensive subgaleal hematoma is individualized. However, treatment for extensive subgaleal hematoma with skull fracture differs from that for a hematoma without skull fracture. Immediate surgery (cito) is recommended before nerve damage occurs in patients.

Minimally invasive neurosurgical techniques may be required, and this minimal invasive technique can be a therapeutic option for subgaleal hematoma with minimal morbidity. Additionally, endoscopic techniques can also be used to treat subgaleal hematoma, but long-term monitoring is still necessary.

Complications

If subgaleal hematoma is not managed properly, it can lead to poor long-term outcomes, including:

• Neonatal encephalopathy
• Seizures
• Brain damage
• Hypoxic-ischemic encephalopathy
• Cerebral palsy
• Periventricular leukomalacia
• Developmental disorders

Prevention

Since most cases of subgaleal hematoma are caused by vacuum or forceps during delivery, prevention can be achieved during pregnancy by routinely monitoring the baby's condition and weight through ultrasound with an obstetrician. With regular check-ups, you can discuss delivery options other than vacuum or forceps with your obstetrician.

When to See a Doctor?

It is recommended to see a doctor immediately if a lump appears on your child's head, especially after delivery or within 12 to 72 hours after delivery. Early treatment of subgaleal hematoma can improve the child's quality of life and prevent further complications.