An extradural and subdural hematoma in a neonate
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《美国医学杂志》
Lokmanya Tilak Municipal Medical College & General Hospital, Sion, Mumbai, India
Abstract
Traumatic brain injury following birth is common in newborn but significant intracranial haematoma following birth injury is not that usual. Even busy pediatric trauma center have about only 1 to 3 % of admission that require neurosurgical care. Extradural haematoma (EDH) associated with intracerebral and subdural haematoma (SDH) is even more rare in newborn. If this is not detected and treated in time, the outcome may be fatal. A case of EDH with subdural and intracerebral haematoma in a 3 days old neonate is presented. Etiology and problems in diagnosis and management are discussed.
Keywords: Newborn; Birth injury; Intracranial haemorrhage
Case report
A three-day-old male child was referred from a maternity home for convulsions and drowsiness. He was a full term baby with vertex presentation, delivered vaginally without episiotomy or any other instrumentation. The process of labor was uneventful without any undue prolongation of any stage of labor. There was no maternal history of cephalopelvic disproportion, bleeding diathesis or epilepsy during pregnancy. There was no history of trauma or fall during antenatal period. Baby cried immediately after birth. The weight of the baby was 2.1 kg at birth. The APGAR score was 8/10 at birth, 1 minute and 5 minutes. The baby was not having any congenital anomalies. No gross scalp swelling was found. The baby was not taking breast-feeds adequately & had 2 episodes of vomiting on 2nd day. On the 3rd day after delivery, the baby had repeated attacks of generalized tonic & clonic seizures followed by drowsiness. On examination, the baby was icteric and drowsy; pupils were 4 mm bilaterally and sluggishly reacting to light. Baby was showing abnormal flexion to painful stimuli on both sides with extensor plantar reflexes and both fontanale were bulging. Complete blood count and ESR were normal. Coagulation profile along with serum biochemistry was within normal limits except serum Bilirubin, which was 12.6 mg%. Ultrasound of the head was performed which has revealed large surface extending intracerebral hyperechoic lesion mainly in the right frontoparietal region. A CT Scan (Brain) revealed 4.5 cm x 3.5 cm x 1.4 cm sized SDH with Intracerebral haematoma of 6 cm x 3.8 cm x 2.8 cm with parietal depressed fracture with subarachnoid hemorrhage with EDH involving right frontoparietal region with mass effect on frontal horn of ipsilateral lateral ventricle. Figure1 and Figure2. As baby was deteriorating neurologically, decision for evacuation of the intracranial hematoma was taken. Before surgery, the baby was showing extensor response to painful stimuli with dilated non-reacting pupils. The baby was taken up for an emergency craniotomy with elevation of depressed fracture with evacuation of EDH & SDH under general anesthesia. An intraparenchymal hematoma was also evacuated and after that brain became lax & pulsatile. The baby has showed signs of improvement within 24 hours. His pupils had started reacting to light and was showing flexion response to painful stimuli. Over a period of four days baby had started opening eyes with spontaneous limb movements with weak cry. On the 8th day after surgery, baby developed cerebrospinal fluid leak, which stopped within 72 hours after starting Tab. Acetazolamide. Breast-feeding was started on 10th day. Baby was discharged on 12th day with spontaneous eye opening, moving all four limbs and crying normally. Follow-up visit at 1 year, baby is doing well with no neurological deficit. Baby was able to sit without support and was walking with support.
Discussion
Trauma is one of the common causes of death in children. The most common cause of head trauma in children is fall. Traumatic injury to the skull and brain in utero is rare[1] and rarely becomes the province of neurosurgeon. Head injury during birth process is common.[2],[3],[4] Traumatic birth injury is defined by Potter as any condition that affects the foetus adversely during labour or delivery, which may be either because of hypoxia or due to mechanical factor.[5] Birth injury falls into 2 categories: injuries produced by the normal force of labour and those produced by obstetric intervention. Mainly, it is a complication of forceps application. Cephalhaematoma, skull bone fracture, intracerebral haematoma, SDH and EDH following cranial birth injury have been mentioned by various authors in different series. Though cases of SDH with intracerebral haematoma are relatively common, EDH is rare. This is because of firm adherence of dura to overlying skull bone in children. Neonatal EDH is extremely rare. Natelson SE studied 42 cases of intracerebral hematoma. Not a single case was associated with EDH [3]. Pollina described 41 consecutive cases of cranial birth injuries without a single case of EDH [6]. Pierre described 17 cases of intracranial hematoma in neonates and there was not even a single case of EDH [7]. On extensive search for literature, not a single case of concomitant occurrence of EDH, SDH and intracerebral hematoma along with overlying bone fracture was found following birth injury in newborn. The proposed mechanism of birth injury during labour is the pressure of the ischial tuberosity against the skull, resulting in bending of the elastic skull of a neonate[12]. This mechanical force results in injury to draining veins giving rise to subdural and intracranial hematoma. Simultaneously, rupture of emissary vein results in collection of blood in the epidural space. Most of the observers have described that intracranial vascular accidents occurring in newborn period are related to venous rather than arterial system. The reason given is the greater susceptibility of veins to changes in the intracranial pressure and direct injury.[8],[9],[10]
Scalp swelling, hypoxia and seizures are the common presentation of intracranial haemorrhage. 37% patients presented with convulsion and 39% with apnea in one series of 41 patients of neonatal intracranial hematoma following birth injury.[6] Our patient presented with recurrent episodes of seizures.
Newborns delivered vaginally and with vertex presentation may have some scalp swelling and in few cases the baby may have a fracture, most common of which is Ping Pong fracture that occurs in the region of parietal bossing and is not associated with visible scalp injury. Intra-uterine depressed skull fracture may be the result of pressure against the maternal symphysis pubis or the promontory of the sacrum as described by Potter and Watson-Jones.[1],[3] There is rarely any associated intracranial injury. This condition can be diagnosed on clinical examination. Plain X-ray may show the degree of deformation. An ultrasound of the skull is easily available bedside tool for the diagnosis and management of intracerebral hematoma in neonates. Ultrasound guided aspiration of the hematoma can be performed in infants but it may precipitate the fresh bleeding also. The hematoma visualized by USG may appear larger on CT Scan as CT can reveal surrounding parenchymal contusion and other multiple small hematoma also.[13] The major indications for obtaining a CT scan in newborn suspected of having an intracranial haematoma are uncontrolled seizure with normal serum biochemistry (Hypoglycemia or Hypocalcaemia), also seizures with neonatal hemorrhagic disorder, lethargy and progressive neurological deterioration. CT scan (brain) is a sensitive radiological tool to diagnose surgically treatable intracranial pathologies in immediate perinatal period.[12]
Small lesions are likely to resolve spontaneously without any surgical intervention. Large lesion (>3cm), which produces mass effect and having midline shift, requires corrective surgery.[12] But the uncontrolled seizures, progressive neurological deterioration or failure to improve with conservative management are also the indications for surgery to decompress the hematoma. Correction of the coagulation profile if present should be done before and blood must be made available before taking to the operation theatre. Proper intraopearative neuromonitoring is essential in a newborn with raised intracranial tension. A pial membrane including the cortical blood supply is easily stripped of by the sucker, which may cause further damage to the normal brain parenchyma.[12] Brain at this age is mostly water and therefore sudden herniation of cerebral tissue may occur when the dura is opened. No effort should be made to remove contused brain tissue because there is a chance of recovery of that damaged tissue. Often the bleeding within the cerebrum is difficult to control because of fluid nature of brain tissue at this age.[12] A properly titrated anti-convulsant should be given in early post-operative period. The prognosis for children who require surgery is poor with 10% mortality and 30% poor outcome.[11]
Conclusion
Birth injury is not uncommon in neonates and head injury following birth injury is an important cause leading to increase in neonatal mortality. Convulsions during neonatal period are common and may lead to diffuse brain injury and perinatal hypoxia, which require no surgical treatment. Occasionally these may be due to intracranial haematoma.
Immediate recognition and surgical intervention when indicated is important, as this condition is remediable. According to literature, these intracranial haematomas following birth injury are not only salvageable but some of the reports including this, at long-term follow-up show active life without neurological deficits.
References
1. Eben Alexander, Jr., MD. Bourtland H. Davis. Intra-Uterine Fracture of Infant's Skull. J Neurosurgery 1969; 30 : 446-454.
2. Abroms IF, McLennan JE, Mandel F. Acute neonatal subdural hematoma following breech delivery. Am J Dis Child 1977; 131 : 192-194.
3. Natelson SE, Sayers MP. The fate of children sustaining severe head trauma during birth. Pediatrics 1973; 51:169-174.
4. Takagi T, Nagai R, Wakabayashi S et al. Extradural hemorrhage in the newborn as a result of birth trauma. Childs Brain 1978; 4 : 306-318.
5. Potter E L. Pathology of foetus and Infant. 2nd ed. Chicago; Year Book Medical Publishers Inc: 1961
6. Pollina J, Dias MS, Li V, Kachurek D, Arbesman M. Cranial birth injuries in term newborn infants. Pediatr Neurosurg 2001; 35(3) : 113-119.
7. Pierre-Kahn A, Renier D, Sainte-Rose C, Hirsch JF. Acute intracranial hematomas in term neonates. Childs Nerv Syst 1986; 2(4): 191-194.
8. Schwartz P. Birth injuries of the newborn. New York, Hafner Publishing Company, 1961.
9. Haller ES, Nesbitt REL Jr, Anderson GW. Clinical and pathological concepts of gross intracranial hemorrhage in perinatal mortality. Obstet Gynec Surgery 1956; 11 : 179.
10. Ross JJ, Dimmette RM. Subependymal Cerebral Hemorrhage in Infancy. Am J Dis Child 1965; 110 : 531.
11. Bruce DA. Central nervous system injury. In Welch KS, Randol JG, Ravitch MM, et al eds. Pediatr Surgery. Chicago; Year Book, 1986: 209-215.
12. Bruce DA. Pediatric head injury. In Wilkins RH, Rengachary SS, eds. Neurosurgery 2nd edn. Mcgraw-Hill; 1996; 2709-2710.
13. Dohrmann GJ, Rubin Jm. Intraoperative ultrasound in neurotraumatology; brain, spinal cord and cauda equina. In Harris P ed. Thoracic and Lumbar Spine and Spinal cord Injuries. Advances in Neurotraumatology, Vol 2. New York; Springer-verlag 1986; 51-64.(Sharma Alok K, Diyora Bat)
Abstract
Traumatic brain injury following birth is common in newborn but significant intracranial haematoma following birth injury is not that usual. Even busy pediatric trauma center have about only 1 to 3 % of admission that require neurosurgical care. Extradural haematoma (EDH) associated with intracerebral and subdural haematoma (SDH) is even more rare in newborn. If this is not detected and treated in time, the outcome may be fatal. A case of EDH with subdural and intracerebral haematoma in a 3 days old neonate is presented. Etiology and problems in diagnosis and management are discussed.
Keywords: Newborn; Birth injury; Intracranial haemorrhage
Case report
A three-day-old male child was referred from a maternity home for convulsions and drowsiness. He was a full term baby with vertex presentation, delivered vaginally without episiotomy or any other instrumentation. The process of labor was uneventful without any undue prolongation of any stage of labor. There was no maternal history of cephalopelvic disproportion, bleeding diathesis or epilepsy during pregnancy. There was no history of trauma or fall during antenatal period. Baby cried immediately after birth. The weight of the baby was 2.1 kg at birth. The APGAR score was 8/10 at birth, 1 minute and 5 minutes. The baby was not having any congenital anomalies. No gross scalp swelling was found. The baby was not taking breast-feeds adequately & had 2 episodes of vomiting on 2nd day. On the 3rd day after delivery, the baby had repeated attacks of generalized tonic & clonic seizures followed by drowsiness. On examination, the baby was icteric and drowsy; pupils were 4 mm bilaterally and sluggishly reacting to light. Baby was showing abnormal flexion to painful stimuli on both sides with extensor plantar reflexes and both fontanale were bulging. Complete blood count and ESR were normal. Coagulation profile along with serum biochemistry was within normal limits except serum Bilirubin, which was 12.6 mg%. Ultrasound of the head was performed which has revealed large surface extending intracerebral hyperechoic lesion mainly in the right frontoparietal region. A CT Scan (Brain) revealed 4.5 cm x 3.5 cm x 1.4 cm sized SDH with Intracerebral haematoma of 6 cm x 3.8 cm x 2.8 cm with parietal depressed fracture with subarachnoid hemorrhage with EDH involving right frontoparietal region with mass effect on frontal horn of ipsilateral lateral ventricle. Figure1 and Figure2. As baby was deteriorating neurologically, decision for evacuation of the intracranial hematoma was taken. Before surgery, the baby was showing extensor response to painful stimuli with dilated non-reacting pupils. The baby was taken up for an emergency craniotomy with elevation of depressed fracture with evacuation of EDH & SDH under general anesthesia. An intraparenchymal hematoma was also evacuated and after that brain became lax & pulsatile. The baby has showed signs of improvement within 24 hours. His pupils had started reacting to light and was showing flexion response to painful stimuli. Over a period of four days baby had started opening eyes with spontaneous limb movements with weak cry. On the 8th day after surgery, baby developed cerebrospinal fluid leak, which stopped within 72 hours after starting Tab. Acetazolamide. Breast-feeding was started on 10th day. Baby was discharged on 12th day with spontaneous eye opening, moving all four limbs and crying normally. Follow-up visit at 1 year, baby is doing well with no neurological deficit. Baby was able to sit without support and was walking with support.
Discussion
Trauma is one of the common causes of death in children. The most common cause of head trauma in children is fall. Traumatic injury to the skull and brain in utero is rare[1] and rarely becomes the province of neurosurgeon. Head injury during birth process is common.[2],[3],[4] Traumatic birth injury is defined by Potter as any condition that affects the foetus adversely during labour or delivery, which may be either because of hypoxia or due to mechanical factor.[5] Birth injury falls into 2 categories: injuries produced by the normal force of labour and those produced by obstetric intervention. Mainly, it is a complication of forceps application. Cephalhaematoma, skull bone fracture, intracerebral haematoma, SDH and EDH following cranial birth injury have been mentioned by various authors in different series. Though cases of SDH with intracerebral haematoma are relatively common, EDH is rare. This is because of firm adherence of dura to overlying skull bone in children. Neonatal EDH is extremely rare. Natelson SE studied 42 cases of intracerebral hematoma. Not a single case was associated with EDH [3]. Pollina described 41 consecutive cases of cranial birth injuries without a single case of EDH [6]. Pierre described 17 cases of intracranial hematoma in neonates and there was not even a single case of EDH [7]. On extensive search for literature, not a single case of concomitant occurrence of EDH, SDH and intracerebral hematoma along with overlying bone fracture was found following birth injury in newborn. The proposed mechanism of birth injury during labour is the pressure of the ischial tuberosity against the skull, resulting in bending of the elastic skull of a neonate[12]. This mechanical force results in injury to draining veins giving rise to subdural and intracranial hematoma. Simultaneously, rupture of emissary vein results in collection of blood in the epidural space. Most of the observers have described that intracranial vascular accidents occurring in newborn period are related to venous rather than arterial system. The reason given is the greater susceptibility of veins to changes in the intracranial pressure and direct injury.[8],[9],[10]
Scalp swelling, hypoxia and seizures are the common presentation of intracranial haemorrhage. 37% patients presented with convulsion and 39% with apnea in one series of 41 patients of neonatal intracranial hematoma following birth injury.[6] Our patient presented with recurrent episodes of seizures.
Newborns delivered vaginally and with vertex presentation may have some scalp swelling and in few cases the baby may have a fracture, most common of which is Ping Pong fracture that occurs in the region of parietal bossing and is not associated with visible scalp injury. Intra-uterine depressed skull fracture may be the result of pressure against the maternal symphysis pubis or the promontory of the sacrum as described by Potter and Watson-Jones.[1],[3] There is rarely any associated intracranial injury. This condition can be diagnosed on clinical examination. Plain X-ray may show the degree of deformation. An ultrasound of the skull is easily available bedside tool for the diagnosis and management of intracerebral hematoma in neonates. Ultrasound guided aspiration of the hematoma can be performed in infants but it may precipitate the fresh bleeding also. The hematoma visualized by USG may appear larger on CT Scan as CT can reveal surrounding parenchymal contusion and other multiple small hematoma also.[13] The major indications for obtaining a CT scan in newborn suspected of having an intracranial haematoma are uncontrolled seizure with normal serum biochemistry (Hypoglycemia or Hypocalcaemia), also seizures with neonatal hemorrhagic disorder, lethargy and progressive neurological deterioration. CT scan (brain) is a sensitive radiological tool to diagnose surgically treatable intracranial pathologies in immediate perinatal period.[12]
Small lesions are likely to resolve spontaneously without any surgical intervention. Large lesion (>3cm), which produces mass effect and having midline shift, requires corrective surgery.[12] But the uncontrolled seizures, progressive neurological deterioration or failure to improve with conservative management are also the indications for surgery to decompress the hematoma. Correction of the coagulation profile if present should be done before and blood must be made available before taking to the operation theatre. Proper intraopearative neuromonitoring is essential in a newborn with raised intracranial tension. A pial membrane including the cortical blood supply is easily stripped of by the sucker, which may cause further damage to the normal brain parenchyma.[12] Brain at this age is mostly water and therefore sudden herniation of cerebral tissue may occur when the dura is opened. No effort should be made to remove contused brain tissue because there is a chance of recovery of that damaged tissue. Often the bleeding within the cerebrum is difficult to control because of fluid nature of brain tissue at this age.[12] A properly titrated anti-convulsant should be given in early post-operative period. The prognosis for children who require surgery is poor with 10% mortality and 30% poor outcome.[11]
Conclusion
Birth injury is not uncommon in neonates and head injury following birth injury is an important cause leading to increase in neonatal mortality. Convulsions during neonatal period are common and may lead to diffuse brain injury and perinatal hypoxia, which require no surgical treatment. Occasionally these may be due to intracranial haematoma.
Immediate recognition and surgical intervention when indicated is important, as this condition is remediable. According to literature, these intracranial haematomas following birth injury are not only salvageable but some of the reports including this, at long-term follow-up show active life without neurological deficits.
References
1. Eben Alexander, Jr., MD. Bourtland H. Davis. Intra-Uterine Fracture of Infant's Skull. J Neurosurgery 1969; 30 : 446-454.
2. Abroms IF, McLennan JE, Mandel F. Acute neonatal subdural hematoma following breech delivery. Am J Dis Child 1977; 131 : 192-194.
3. Natelson SE, Sayers MP. The fate of children sustaining severe head trauma during birth. Pediatrics 1973; 51:169-174.
4. Takagi T, Nagai R, Wakabayashi S et al. Extradural hemorrhage in the newborn as a result of birth trauma. Childs Brain 1978; 4 : 306-318.
5. Potter E L. Pathology of foetus and Infant. 2nd ed. Chicago; Year Book Medical Publishers Inc: 1961
6. Pollina J, Dias MS, Li V, Kachurek D, Arbesman M. Cranial birth injuries in term newborn infants. Pediatr Neurosurg 2001; 35(3) : 113-119.
7. Pierre-Kahn A, Renier D, Sainte-Rose C, Hirsch JF. Acute intracranial hematomas in term neonates. Childs Nerv Syst 1986; 2(4): 191-194.
8. Schwartz P. Birth injuries of the newborn. New York, Hafner Publishing Company, 1961.
9. Haller ES, Nesbitt REL Jr, Anderson GW. Clinical and pathological concepts of gross intracranial hemorrhage in perinatal mortality. Obstet Gynec Surgery 1956; 11 : 179.
10. Ross JJ, Dimmette RM. Subependymal Cerebral Hemorrhage in Infancy. Am J Dis Child 1965; 110 : 531.
11. Bruce DA. Central nervous system injury. In Welch KS, Randol JG, Ravitch MM, et al eds. Pediatr Surgery. Chicago; Year Book, 1986: 209-215.
12. Bruce DA. Pediatric head injury. In Wilkins RH, Rengachary SS, eds. Neurosurgery 2nd edn. Mcgraw-Hill; 1996; 2709-2710.
13. Dohrmann GJ, Rubin Jm. Intraoperative ultrasound in neurotraumatology; brain, spinal cord and cauda equina. In Harris P ed. Thoracic and Lumbar Spine and Spinal cord Injuries. Advances in Neurotraumatology, Vol 2. New York; Springer-verlag 1986; 51-64.(Sharma Alok K, Diyora Bat)