Cranial epidural hematoma related to an accidental fall from mother's lap in a neonate.

Dear Sir,

An extradural hematoma is a collection of blood between the calvarial bone and the dura. Extradural hemorrhage is very rare in children in comparison to other types of intracranial hemorrhage.[12] Extradural hematoma comprises of 2–3% of all pediatric head injuries and it is even rarer in neonates and infants due to tight adherence of the dura to the skull, poor development of dura mater vessels and folding of the skull rather than fracture.[34] We present here a rare case of a newborn suffering from a fall from mother's lap causing epidural hematoma (EDH) which is discussed along with the review of current literature.

Our case was of a term, 2.6 kg, male baby delivered by spontaneous vaginal delivery at our hospital. The process of labor was uneventful, and there was no prolongation of labor. The baby was delivered without any episiotomy or instrumentation. The baby cried at birth and did not require any resuscitation at the labor room. Apgar score was 8/10 at birth, 1 min and 5 min. However, the baby suffered an accidental fall from mother's lap in postnatal ward. On admission to the neonatal care unit, the heart rate was 152/min, respiratory rate was 54/min and blood pressure was 82/40 mm Hg. The baby was found to have a left parieto temporal hematoma and scalp swelling. The baby became progressively pale, lethargic and drowsy and after 6 h developed recurrent generalized tonic clonic convulsions. The hematoma size increased, the anterior fontanelle was full and the pupils were bilaterally equal but sluggishly reacting. An urgent noncontrast computed tomography (CT) scan brain was done which revealed a large extradural hemorrhage - 5 cm in antero-posterior diameter and 2.2 cm in width in left parietal area with overlying scalp hematoma [Figure 1]. In view of the recurrent seizures and deteriorating condition of the baby, left parietal craniotomy was done, and the hematoma was evacuated. The postoperative period was uneventful, the condition of the baby improved, seizures were controlled, breast feeding was initiated and the baby was discharged on the 9th postoperative day with normal crying and active movement of all four limbs. In follow-up visits, no neurological deficit was found, and attainment of developmental milestones was appropriate for the age.

Figure 1

Computed tomography scan showing large extradural hemorrhage - 5 cm in antero-posterior diameter and 2.2 cm in width in left parietal area with overlying scalp hematoma

Traumatic head injuries lead to 2% of neonatal deaths.[5] Though birth injuries are common in neonates – neonatal EDH is extremely rare. In a study by Takagi et al., only 2% of the 134 autopsied infants with intracranial hemorrhage were found to have EDH.[6] Less than 50 cases have been reported in the literature.[7] Traumatic extradural hematoma constitutes a distinct clinicopathological entity in children.[8] A retrospective study comprising of 31 study subjects below 2 months of age revealed a fall as the commonest etiology.[5] Irritability or persistent crying was found to be the most common symptom whereas cephalhematoma was found to be the most common sign.[5] Heyman et al. found parietal region as the most common site of EDH and skull fracture. EDH may have an associated skull fracture in 50% to 66% of cases.[1] Cephalhematoma is often accompanied by liquid EDH and is seen in nearly 16.6-75% of the cases.[1]

Rupture of the middle meningeal arteries, veins and fractures are the causes of EDH in adults. However, as the middle meningeal artery is not embedded in the cranial bones, it moves freely between the skull and hence, is less susceptible to injury in the neonates. Venous bleeding forms the major source of bleeding in neonates.[29] An EDH can often be associated with a fracture, but the presence of a fracture is not a rule in the newborn.[1] In our case also, no fracture was detected on imaging or peroperatively.

Neonatal traumatic head injuries are rarely symptomatic and usually require careful monitoring and conservative management. Skull plasticity, which is specific in newborns, leads to rapid adaptation to intracranial collections.[4] Seizures and hypotonia were found to be the commonest symptoms in traumatic EDH. In our case also, generalized tonic clonic seizures were present. Though conservative management is advocated in most cases, when untreated, it may prove to be fatal due to the occurrence of tentorial herniation. EDH can be diagnosed early by CT or magnetic resonance imaging scans.

Treatment of neonatal EDH is controversial. Treatment may be conservative, surgical or interventional needle aspiration. Vachharajani and Mathur[10] described ultrasound guided needle aspiration of the epidural hematoma. Percutaneous aspiration was the preferred modality of treatment when possible, and surgery was done only in cases of its failure. Vinchon et al.[4] described the indications for surgical treatment as poor neurological tolerance, intracranial hypertension, unstable vital signs and brain shift on imaging. Heyman et al.[1] considered thickness of hematoma, shifting of brain, presence of depressed cranial fracture and hydrocephalus as indicators for surgical management. Though large lesions >3 cm causing mass effect and midline shift needed surgical correction, uncontrolled seizures, progressive neurological deterioration and failure to respond to conservative management were found to be other indicators for surgical management.[11]

Epidural hematoma are seldom seen in neonates but should always be kept in mind in case of neonatal head injuries. Early diagnosis, careful monitoring and surgical management when indicated will help in decreasing mortality due to this cause.