Pathophysiology of intracranial epidural haematoma following birth

Neonatal Acute Epidural Hematoma: A Case Report and Literature Review

We present a rare case of an acute epidural hematoma (EDH) in a neonate. The EDH was caused by a fall during natural vaginal delivery. The clinical findings were normal after fall and the first ultrasonographic study did not show any hematomas. A computed tomography scan on the second day after delivery showed an EDH with 20 mm thickness extending through a skull fracture into subgaleal space. We performed a craniotomy and removed the EDH and subgaleal hematoma. After the surgery we performed follow-up twice ultrasonographic study for seeking probable hematoma recurrence. The patient was discharged after postoperative 3 days without any neurological deficits.

Craniocerebral birth injuries in term newborn infants: a retrospective series

OBJECTIVE

In an attempt to further define the spectrum of cranial birth injuries, we analyzed 21 consecutive cranial birth injuries in term neonates presenting to the neurosurgical department of our institution over the period 1994-2015.

METHODS

We performed a retrospective chart review from the medical records of the University Hospitals of the KU Leuven, from 1994 to 2015. We included 21 infants of 36-week gestational age or older with a diagnosis of cranial birth injury. The types and locations of injuries, the presenting signs, symptoms and their timing, and the required treatment(s) were recorded. Various maternal and neonatal factors and the mode of delivery were recorded. We recorded the different modes of delivery rates at our institution in the year 2013 and the rates in the Flemish community between 1995 and 2013, in order to compare the mode of delivery rates in the study group with current practice at our institution and with general practice over the years in the Flemish community.

RESULTS

The most common clinical presentations were swelling (43% of cases) and seizures (19% of cases). Average Apgar scores were 6.57 at 1 min and 8.43 at 5 min; 48% of children had abnormally low Apgar scores at 1 min and 9.5% had abnormally low scores at 5 min. The most common intracranial lesion was skull fractures (33%). Operative treatment was required in 11 infants (52%). One infant died. Assisted mechanical delivery by either forceps and/or vacuum extraction occurred in 43% of infants. In comparison, in the year 2013, only 13.97% of deliveries at our institution were mechanically assisted. Over the period 1995-2013, the highest mechanically assisted delivery rates in the Flemish community were 14.1% in 1996.

CONCLUSION

Although our series is too small to make firm conclusions, it is remarkable that the rates of assisted mechanical deliveries in our series far exceeded the assisted mechanical delivery rates at our institution in the year 2013 and even the highest vacuum and forceps delivery rates in the Flemish community over the period 1995-2013.

Manifestations of Birth Trauma at the Forensic Pediatric Autopsy

Despite a greatly decreasing incidence of birth injuries over the past several decades with birth trauma currently accounting for less than 2% of neonatal deaths, birth trauma continues to be a significant cause of morbidity and mortality. Birth trauma is usually recognized by obstetricians and pediatricians, particularly when associated with a difficult delivery; therefore many birth injuries are diagnosed and documented in the neonatal period. Other delivery-related trauma may remain clinically silent without premortem identification. The challenge for the pathologist at autopsy is to correlate a history of birth trauma with injuries seen at autopsy, and to interpret injuries existing at death to accurately include or exclude birth trauma as a potential cause. Recognition of the spectrum of birth trauma is important when considering other accidental and nonaccidental mechanisms of injury, particularly in cases of unwitnessed perinatal death following delivery of a concealed pregnancy or in cases of alleged nonaccidental trauma. Discussed here is a general review of birth trauma that may be seen in a forensic setting to aid in interpretation of injuries that can be encountered.

Spontaneous perinatal epidural haemorrhage in a newborn

A full-term neonate, born by caesarean section, presents with focal seizures. EEG and cranial ultrasound are normal. MRI of the cerebrum shows an epidural haematoma. Perinatal intracranial haemorrhage in the full-term newborn is an important cause of morbidity and mortality. Most perinatal intracranial haemorrhages are located either subdural or intracerebral, rarely epidural. Epidural haemorrhage is usually a complication of assisted delivery, however it may also occur without forcipal or vacuum extraction, as demonstrated in this case. An epidural haemorrhage should be suspected on clinical findings, even in the absence of an assisted delivery. As cranial ultrasound sonography often misses epidural haemorrhage due to parietal location of the haemorrhage, the diagnosis needs either cerebral CT or MRI.

Epidural hematoma

Epidural hematomas are rare birth injuries, and spontaneous presentation is exceptional. We present 2 cases of newborns with spontaneous epidural hematomas after delivery. In both cases, cerebral hemorrhage was associated with skull fracture and cephalohematoma. One newborn presented with neurologic symptoms in the form of convulsions, whereas the other was asymptomatic. Confirmation of the diagnosis was made by cranial computed tomography. Both cases were treated surgically by craniotomy. Follow-up showed normal neurologic development.

Ultrasound-guided needle aspiration of epidural hematoma in a neonate after vacuum-assisted delivery

INTRODUCTION

Epidural hematoma (EDH) is a rare complication of vacuum-assisted delivery in neonates. Although the standard treatment of EDH is surgical evacuation via craniotomy, it is an invasive procedure in neonates, and less invasive methods may be favored for hematoma evacuation.

CASE REPORT

We report a case of 5-day-old infant with a massive EDH, cephalohematoma, and a depressed fracture, which were secondary to a vacuum-assisted delivery and cured by ultrasound-guided needle aspiration and drainage. Neonatal EDH may be different from adult counterpart in that the former is more liquefied and is amenable to needle aspiration than the latter. Although needle aspiration is a blind procedure, addition of transcranial ultrasound not only ensures safety by visualizing the tip of the needle but also makes real-time evaluation of the residual hematoma volume possible.

Rapidly calcified epidural hematoma in a neonate

We report a very rare case of a rapidly calcified chronic epidural hematoma (EDH) in a neonate. A 26-day-old female infant was referred to us from a regional hospital because of drowsy mentality and a seizure attack. She was delivered through caesarian section because normal spontaneous vaginal delivery was prolonged and failed. At birth, mild scalp swelling was found on the right frontal area. Scalp swelling was spontaneously resolved and she was discharged without any problems. On the 25th day after her birth, the baby presented with drowsiness and hypotonia following a generalized tonic-clonic seizure. Magnetic resonance imaging (MRI) and a computed tomography (CT) scan revealed a chronic EDH that had a thick layer of calcification. A small burr-hole trephination was performed and a single silastic drainage catheter was inserted. After the operation, a total of 12 ml of liquefied hematoma was drained, and the patient's mentality improved from drowsiness to alertness. The patient was asymptomatic when discharged.

Birth injury of the cranium and central nervous system

Birth injury of the scalp, skull and central nervous system (CNS) is a well-recognized complication of a difficult delivery. The rate of birth trauma has dropped precipitously and now accounts for less than 2% of neonatal deaths. Despite this dramatic decrease in birth-trauma mortality significant injuries still occur. A variety of risk factors clearly predispose certain infants to birth-related injury. Recent neuroradiology studies indicate that intracranial hemorrhage, even in asymptomatic infants, is not rare. Pathologists' (neuropathologists and forensic pathologists) appreciation of the spectrum of birth injuries and their sequelae is critical in order to be able to distinguish these from inflicted injuries and post-mortem changes.

Head trauma after instrumental births

Instrumental vaginal delivery involves the use of the vacuum extractor or obstetric forceps to facilitate delivery of the fetus. It is associated with substantial risk of head injury, including hemorrhage, fractures, and, rarely, brain damage or fetal death. This review article describes the different types, etiology, pathophysiology, risk factors, and clinical features of head trauma after instrumental birth, along with their management and prevention strategies.