On the management of neonatal tentorial damage. Eight case reports and a review of the literature

Newborn with severe supratentorial subdural hematoma due to laceration of the tentorium cerebelli

PURPOSE

A rare case of a newborn girl born by a normal vaginal delivery who developed a severe supratentorial subdural hematoma due to a laceration in the tentorium cerebelli is presented.

METHODS AND RESULTS

The girl, born by normal vaginal delivery at 39 weeks and 4 days of gestation, showed an intermittent decrease in oxygen saturation and bulging of the anterior fontanelle. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a subdural hematoma centered in the left occipital region with a midline shift. Hematoma evacuation with craniotomy was performed, and the source of bleeding was a laceration of the tentorium cerebelli.

CONCLUSION

Severe supratentorial subdural hematomas can occur due to laceration of the tentorium cerebelli even in a normal vaginal delivery.

Cranial Ultrasound Is an Important Tool in the Recognition of Life-Threatening Infratentorial Hemorrhage in Newborns

Timely detection of severe infratentorial hemorrhage in neonates is crucial, especially in case of life-threatening brain stem compression and/or acute obstructive hydrocephalus, which need lifesaving neurosurgical intervention. Although the detection of infratentorial hemorrhage by ultrasound scanning is often considered as difficult, the use of additional acoustic windows and recognition of characteristic ultrasound features facilitate early diagnosis. In this case series, we report on newborns with severe, symptomatic infratentorial hemorrhage detected primarily by cranial ultrasound. We demonstrate the characteristic ultrasound features present in all cases and discuss how ultrasound diagnosis contributed to early diagnosis and treatment.

Subdural haematoma in neonates following forceps-assisted delivery: case series and review of the literature

PURPOSE

Subdural haematoma (SDH) is a recognised complication of forceps-assisted delivery (FAD). There are no guidelines regarding its management. This study aims to provide a better insight into the management and outcomes of neonatal SDH post-FAD.

METHODS

Retrospective review of our neonatal database and systematic review of the literature for neonatal cases that presented with SDH after FAD. Retrospective neurosurgical database search for cases of neonatal SDH post-FAD managed in our unit between January 2007 and January 2017. Systematic review of the literature was performed using PRISMA guidelines. The inclusion criteria are as follows: (1) neonates; (2) forceps-assisted delivery; (3) evidence of SDH on imaging, with or without other traumatic lesions.

RESULTS

A literature search yielded nine studies with 30 patients meeting our inclusion criteria. In addition, four cases were identified from our institutional database. Forty-two percent (n = 14) had their SDH managed surgically, with subsequent full neurological recovery in 57%. In comparison, 95% (n = 18) of the conservatively managed patients made a full recovery. Hydrocephalus was present in 1/19 and 11/14 of the conservatively managed and surgically managed patients respectively.

CONCLUSIONS

Conservative management can lead to a full neurological recovery in SDH following FAD in neonates. However, a significant minority may still need neurosurgical intervention for the SDH or subsequent hydrocephalus; therefore, we advocate early transfer to a specialist neuroscience centre.

The management of birth-related posterior fossa hematomas in neonates

BACKGROUND

Symptomatic posterior fossa hematoma in the term newborn is rare.

OBJECTIVE

To report on the management and outcome of posterior fossa subdural hematoma (PFSDH) in neonates.

METHODS

A retrospective analysis of the department database and clinical notes of neonates admitted since 1985 with a PFSDH was performed together with a literature review of similar case series.

RESULTS

Sixteen patients were included. The median gestational age was 40 weeks with a high proportion of primiparous mothers (n = 9) and forceps delivery (n = 9). Nine neonates had symptoms of brainstem dysfunction within the first 24 hours of life, whereas the other 7 had a delayed presentation (median 4 days) with signs of raised intracranial pressure due to hydrocephalus. Each patient had a cranial ultrasound followed by computed tomography scan that showed the PFSDH. Eleven neonates required surgical evacuation of the PFSDH, whereas hydrocephalus was managed by transient external ventricular drainage in 2 further patients. Eventually, 2 neonates required a permanent ventriculoperitoneal shunt. Five neonates had no operative intervention. With a mean follow-up of 7.8 years, 2 patients had mild developmental delay and 1 had severe developmental delay. The 13 other patients had a normal development.

CONCLUSION

In neonates with a PFSDH, surgery can be safely performed in those who have clinical and radiological signs of brainstem compression or hydrocephalus. A small number of neonates require a ventriculoperitoneal shunt in the long term. Initial aggressive resuscitation should be performed even in cases of initial severe brainstem dysfunction because of the good long-term neurological outcome.

Traumatic intracranial hemorrhage in newborns

INTRODUCTION

Neonatal traumatic head injuries (NTHI) can be life-threatening and require aggressive treatment. The indications, techniques, and results of brain decompression are not well defined in the literature.

METHODS

We studied prospectively cases of NTHI with intracranial traumatic lesions; skull fractures without underlying lesions were not included. We treated 17 cases of NTHI: 7 patients had a subdural hematoma, 3 had an extradural hematoma, and the others had subarachnoid hemorrhage. Surgical evacuation of intracranial clots was performed in 7 cases, by needle aspiration in 5 and by craniotomy in 2 patients with extradural hematomas.

RESULTS

The outcome was favorable in all but one patient, who had hemophilia A, and died of rebleeding at the age of 2 months.

CONCLUSION

Surgical decompression of intracranial hematomas due to NTHI is often unnecessary; however, it may be required in emergency because of poor clinical tolerance. Whenever possible, percutaneous needle aspiration is the treatment of choice.

Controversies in the use of the vacuum extractor

Operative pelvic delivery is an important component of obstetrical care. Vacuum extraction assumes a prominent role, and when appropriately performed, has been proven safe and effective. However, controversies continue to exist. Historical background and review of the latest literature are presented to delineate these issues and promote consensus and direct research to continue to provide the safest means of delivery for the mother and baby.

Imaging of pediatric head trauma

This article discusses all types of traumatic head injury in infants, children and adolescents. Neuroimaging patterns of injury help to make the precise diagnosis and assists in monitoring responses to therapy.

Retroclival extradural hematoma is a magnetic resonance imaging diagnosis

An epidural hematoma of the clivus is reported in a 16-year-old boy after a motor vehicle accident. The diagnosis was made by magnetic resonance imaging. Only five similar cases have been reported in the literature. The patient was treated conservatively and recovered without neurological deficits. The mechanism of injury and formation of the hematoma in this region are discussed.

[Posterior fossa hemorrhage in newborns following vaccum extractor delivery]

AIM

To emphasize the risk of posterior fossa hemorrhage in newborns following vacuum extraction.

PATIENTS AND METHODS

Over a period of 26 months (September 1996-December 1998), seven patients who underwent delivery with the vacuum extractor had symptoms of brain stem compression, related to posterior fossa hemorrhage. They were referred to the neonatal intensive care unit. Some parameters had been analyzed: gestational period, delivery circumstances, gestational age, parameters of newborn, indications of vacuum extraction and other paraclinical investigations (biological and radiological).

RESULTS

Ultrasound scan revealed intracranial hemorrhage in five cases of seven; mean time of diagnosis was 10 hours of age. All patients presented symptoms of brain stem compression. Mean period of follow-up was 22 months: six of seven patients had a normal neurodevelopment. One patient had a cerebellar ataxia, another one a palsy of the IIIrd cranial nerve.

CONCLUSION

Analyses of posterior fossa by ultrasound scan should be made for newborns delivered by vacuum extractor, especially if they had symptoms of brain stem compression.

Management and outcomes of posterior fossa subdural hematomas in neonates

OBJECTIVE

To review and analyze a contemporary series of 15 neonates who were treated for posterior fossa subdural hematomas (PFSDHs) during the era of computed tomography and magnetic resonance imaging.

METHODS

A retrospective chart review identified all neonates with PFSDHs for whom neurosurgical consultations were obtained for treatment planning.

RESULTS

There were nine male and six female patients. The mean gestational age was 39 weeks. Nine of the 15 mothers of the patients were primiparous. Instrument-assisted delivery (forceps and/or vacuum extractor) was undertaken for seven patients. The mean birth weight of the infants was 3165 g (range, 2160-3930 g). The mean 5-minute Apgar score was 7.5. Symptoms of PFSDH developed within the first 24 hours of life in 13 neonates. The predominant symptoms and signs were failure to thrive, irritability, seizures, apnea, and bradycardia. Lumbar punctures to rule out central nervous system sepsis were performed in six neonates. Hemograms revealed that six neonates were anemic with low hemoglobins, five had low platelets, and four had abnormal prothrombin and/or partial thromboplastin times at the time of diagnosis. Computed tomography established the diagnosis of PFSDH in all cases. Magnetic resonance imaging was performed for two neonates. The median time to diagnosis by imaging studies was 10 hours after birth. Surgical evacuation of the PFSDHs was performed in eight neonates. Seven neonates were followed conservatively with serial imaging studies. There was no mortality in either treatment group. Follow-up ranged from 2 to 10 years, with a mean of 4.5 years. Functional outcome assessment revealed that seven neonates were neurodevelopmentally normal, three were mildly delayed, two were moderately delayed, and three were profoundly delayed. In addition to traumatic causes of the PFSDHs, three neonates were observed to have coagulation disturbances at birth and one was observed at follow-up to have a posterior fossa medulloblastoma that had bled at birth.

CONCLUSION

PFSDHs are rare but important lesions to diagnose early in the neonatal period. Surgery can be life-saving when performed in a timely manner for signs and symptoms of brain stem dysfunction. A search for an underlying cause predisposing to a PFSDH may, on occasion, reveal a coagulation disturbance or a neoplasm that will require additional therapeutic considerations.