Neonatal Head Ultrasound: Extracranial Hemorrhage Jenelle Beadle, RDMS Inland Imaging May 2017

Scalp Hematomas Subdivided by location (from superficial to deep) Caput Succedaneum: subcutaneous Suk-se-day-nee-um Most common secondary to vacuum assisted delivery Subgaleal Hematoma: between the galea aponeurosis and periosteum Cephalohematoma: between the skull & periosteum Bound by suture lines Epidural/subdural hemorrhages are beneath the skull and cannot be reliably detected with ultrasound

Scalp Hematomas Subdivided by location, BUT Ultrasound cannot identify the layers of the scalp, so we must generally rely on other features to distinguish one type of hematoma from another

Scalp Hematomas Distinguishing Features Caput Succedaneum: poorly defined; localized soft tissue edema Maximal size at birth & gradual resolves over hours or days Vague borders; pitting edema Subgaleal Hematoma: poorly defined; wide-spread (may extend to orbits) Presents after birth & progressively worsens; resolves over 2-3wks Blood volume may be massive (may be associated with coagulopathy) Associated with skull fracture Cephalohematoma: well defined; does not cross sutures Presents after birth & increases for 12-24hrs; resolves over weeks or months Rarely severe

Caput Succedaneum Caused by pressure of skull against dilating cervix or vacuum assisted delivery Located at the presenting portion of the skull or vacuum placement site

Caput Succedaneum Caused by pressure of skull against dilating cervix or vacuum assisted delivery Located at the presenting portion of the skull or vacuum placement site “cone head” Vaginal delivery only Not associated with skull fracture

Caput Succedaneum Caused by pressure of skull against dilating cervix or vacuum assisted delivery Poorly defined; localized soft tissue edema pitting

Caput Succedaneum Caused by pressure of skull against dilating cervix or vacuum assisted delivery Poorly defined; localized soft tissue edema Maximal size at birth & gradual resolves over hours or days Ultrasound is typically not ordered/needed

Subgaleal Hematoma Caused by vacuum/forceps assisted delivery or head trauma Associated with coagulopathy May occur spontaneously

Subgaleal Hematoma Caused by vacuum/forceps assisted delivery or head trauma Associated with coagulopathy May occur spontaneously Associated with skull fracture

Subgaleal Hematoma Caused by vacuum/forceps assisted delivery or head trauma Wide-spread Sub-galeal space covers the entire cranium From eyes to the nape of the neck From ear to ear

Subgaleal Hematoma Caused by vacuum/forceps assisted delivery or head trauma Wide-spread Not limited by sutures No barriers to limit bleeding Blood will shift

Subgaleal Hematoma Blood loss may be massive Usually develop slowly (hours/days) Mortality reported from 12-25% Symptoms signify extensive blood loss Increased circumference Decreased hematocrit; increased bilirubin Neurological disturbances (seizures, etc.)

Subgaleal Hematoma

Subgaleal Hematoma (fracture)

Cephalohematoma Caused by vacuum/forceps assisted delivery Incidence: 1-2% of live births Increases with instrument delivery

Cephalohematoma Caused by vacuum/forceps assisted delivery Bound by sutures Usually over the parietal bone(s) Well defined margins Firm

Cephalohematoma Caused by vacuum/forceps assisted delivery Bound by sutures Usually over the parietal bone(s) Well defined margins Firm Cephalohematoma

Cephalohematoma Caused by vacuum/forceps assisted delivery Bound by sutures Usually over the parietal bone(s) Well defined margins Firm

Cephalohematoma Caused by vacuum/forceps assisted delivery Bound by sutures May calcify

Take home message: Identify relationship of hematoma to sutures