<%server.execute "isdev.asp"%> Cranial epidural hematoma related to an accidental fall from mother's lap in a neonate Chakraborty S, Dey PK, Chatterjee S - J Pediatr Neurosci
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LETTER TO THE EDITOR
Year : 2015  |  Volume : 10  |  Issue : 1  |  Page : 82-83
 

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


1 Department of Paediatrics, Medical College, Kolkata, West Bengal, India
2 Department of Paediatrics, Midnapore Medical College, Kolkata, West Bengal, India
3 Department of Neurosurgery, Medical College, Kolkata, West Bengal, India

Date of Web Publication2-Apr-2015

Correspondence Address:
Sohini Chakraborty
H2/67, Satellite Township, Shakuntala Park, Kolkata - 700 061, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1817-1745.154370

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How to cite this article:
Chakraborty S, Dey PK, Chatterjee S. Cranial epidural hematoma related to an accidental fall from mother's lap in a neonate. J Pediatr Neurosci 2015;10:82-3

How to cite this URL:
Chakraborty S, Dey PK, Chatterjee S. Cranial epidural hematoma related to an accidental fall from mother's lap in a neonate. J Pediatr Neurosci [serial online] 2015 [cited 2019 May 19];10:82-3. Available from: http://www.pediatricneurosciences.com/text.asp?2015/10/1/82/154370


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. [1],[2] 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. [3],[4] 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 9 th 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

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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. [2],[9] 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.

 
   References Top

1.
Heyman R, Heckly A, Magagi J, Pladys P, Hamlat A. Intracranial epidural hematoma in newborn infants: Clinical study of 15 cases. Neurosurgery 2005;57:924-9.  Back to cited text no. 1
    
2.
Yamamoto T, Enomoto T, Nose T. Epidural hematoma associated with cephalohematoma in a neonate - Case report. Neurol Med Chir (Tokyo) 1995;35:749-52.  Back to cited text no. 2
    
3.
Uhing MR. Management of birth injuries. Clin Perinatol 2005;32:19-38, v.  Back to cited text no. 3
    
4.
Vinchon M, Pierrat V, Tchofo PJ, Soto-Ares G, Dhellemmes P. Traumatic intracranial hemorrhage in newborns. Childs Nerv Syst 2005;21:1042-8.  Back to cited text no. 4
    
5.
Leestma JE. Forensic neuropathology. In: Duckett S, editor. Pediatric Neuropathology. Baltimore: Williams and Wilkins; 1995. p. 243-83.  Back to cited text no. 5
    
6.
Takagi T, Nagai R, Wakabayashi S, Mizawa I, Hayashi K. Extradural hemorrhage in the newborn as a result of birth trauma. Childs Brain 1978;4:306-18.  Back to cited text no. 6
    
7.
Noetzel MJ. Perinatal trauma and cerebral palsy. Clin Perinatol 2006;33:355-66.  Back to cited text no. 7
    
8.
Ciurea AV, Kapsalaki EZ, Coman TC, Roberts JL, Robinson JS 3 rd , Tascu A, et al. Supratentorial epidural hematoma of traumatic etiology in infants. Childs Nerv Syst 2007;23:335-41.  Back to cited text no. 8
    
9.
Hamlat A, Heckly A, Adn M, Poulain P. Pathophysiology of intracranial epidural haematoma following birth. Med Hypotheses 2006;66:371-4.  Back to cited text no. 9
    
10.
Vachharajani A, Mathur A. Ultrasound-guided needle aspiration of cranial epidural hematoma in a neonate: Treating a rare complication of vacuum extraction. Am J Perinatol 2002;19:401-4.  Back to cited text no. 10
    
11.
Sharma AK, Diyora BD, Shah SG, Pandey AK, Mamidanna R. An extradural and subdural hematoma in a neonate. Indian J Pediatr 2005;72:269.  Back to cited text no. 11
    


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