Surgical Treatment of Ossified Cephalhematoma: A Case Report and Review of the Literature

Surgical Treatment of Ossified Cephalhematoma in Young Child

Cephalhematoma is a subperiosteal collection of blood. The lesion generally spontaneously resolves, but if cephalhematoma persists beyond this period, it typically begins to ossify and may require surgical treatment for correction. The incidence of ossified cephalhematoma is rare, and its pathogenesis is unclear. There have been reports of surgical treatment of ossified cephalhematoma in newborns and infants, but few reports in 5-year-old children. We experienced the surgical treatment of an ossified cephalhematoma in a 5-year-old boy. We performed periosteal reattachment with onlay bone autograft. Follow-up examination at 2 years revealed a good cosmetic result and a computed tomography scan showed excellent reconstitution of the contour of the skull.

Traumatic Birth Injury in a Term Neonate

Cephalohematoma is among the most common forms of birth trauma. It is described as a benign collection of blood above the skull and is associated with prolonged or difficult deliveries. We present the case of a term male born at 39 weeks of gestation with a large cephalohematoma and additional features of caput succedaneum. The patient's condition was successfully treated with minimal intervention and close observation. This case report is aimed at illustrating an atypical presentation of cephalohematoma and discussing the potential sequelae of extracranial birth trauma.

Management of Calcified Cephalohematoma of Infancy: The University of Michigan 25-Year Experience

BACKGROUND

Cephalohematoma of infancy is the result of a subperiosteal blood collection that usually forms during birth-related trauma. A small proportion of cephalohematomas can calcify over time, causing a permanent calvarial deformity that is only correctable with surgery. The authors present a technique for the excision and reconstruction of calcified cephalohematoma and their management experience over the past 25 years.

METHODS

All patients with a diagnosis of calcified cephalohematoma between 1994 and 2019 were identified. Patients were included if the diagnosis was confirmed by a pediatric plastic surgeon or a neurosurgeon. All patients underwent surgical evaluation followed by surgical intervention or observation. Patient demographics and potential risk factors for both surgical and nonsurgical groups were compared using chi-square or Fisher's exact test. Additional data were collected for the surgical cohort.

RESULTS

Of 160 infants diagnosed with cephalohematoma, 72 met inclusion criteria. Thirty patients underwent surgical treatment. There was no significant difference in demographics, baseline characteristics, or potential risk factors between the operative and nonoperative groups. Mean age at the time of surgery was 8.6 months. Twenty-one surgical patients (70 percent) required inlay bone grafting. All surgery patients had improvement in calvarial shape. The main risk of surgery was blood loss requiring transfusion [eight patients (26.7 percent)]. Thirteen percent of patients experienced minor complications.

CONCLUSIONS

This series of 72 children with calcified cephalohematomas, 30 of whom required surgical intervention, is one of the largest to date. The technique presented herein demonstrated excellent surgical outcomes by restoring normal cranial contours and was associated with a low complication profile.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Rarely Seen Intradiploic Skull Hematoma in Infants

ABSTRACT

Although the first intradiploic hematoma (IH) case was reported in 1934, only 7 infant cases were reported in the literature. The authors present 2 IH cases, without birth trauma or bleeding disorder, which were treated surgically. IH is also included in the differential diagnosis of babies with a skull deformity. Computed tomography and magnetic resonance imaging modalities should be used together in diagnosis and treatment. The authors believe that the surgery to treat skull deformity because of IH in babies should be planned in the early period.

Ossified Encapsulated Cephalhematoma

ABSTRACT

Ossified cephalhematoma is a rare congenital condition that may be found if newborn cephalhematoma is not resolved. Here, however, the authors report an exceptional case of an 8-month-old baby presenting with an ossified cephalhematoma in the right parieto-occipital area. Pre-operative imaging showed a calcified subperiosteal hematoma. He underwent hematoma excision with bone contouring procedures. A histopathological study showed hemosiderin-laden macrophages with blood and pseudocyst walls. The authors also discuss the possible pathogenesis of the ossified cephalhematoma and its treatment.

Preoperative cephalhematoma size measured with computed tomography predicts intraoperative bleeding in pediatric patients undergoing cranioplasty

Background

Cranioplasty for the treatment of cephalhematomas in small infants with limited blood volume is challenging because of massive bleeding. This study aimed to elucidate the correlation between cephalhematoma size and intraoperative blood loss and identify criteria that can predict large intraoperative blood loss.

Methods

We reviewed the medical records of 120 pediatric patients aged less than 24 months who underwent cranioplasty for treatment of a cephalhematoma. The cephalhematoma sizes in preoperative brain computed tomography (CT) were measured using ImageJ.

Results

Pearson correlation showed that the cephalhematoma size in the pre-operative brain CT was weakly correlated with intraoperative blood loss (Pearson coefficient = 0.192, P = 0.037). In a multivariable logistic regression analysis, a cephalhematoma size greater than 113.5 cm³ was found to be a risk factor for large blood loss. The area under the curve in the receiver operating characteristic plot of the multivariable model was 0.714 (0.619–0.809).

Conclusions

A cephalhematoma size cutoff value of 113.5 cm³, as measured in the preoperative CT imaging, can predict intraoperative blood loss exceeding 30% of the total body blood volume. The establishment of a transfusion strategy prior to surgery based on cephalhematoma size could be useful in pediatric cranioplasty.

Observational Case Analysis of Neonates With Large Cephalohematoma

Introduction

Cephalohematomas in the newborn period are related to the accumulation of blood between the bone and periosteum as a result of a series of adverse conditions during labor. The optimal approach to cephalohematoma cases is still unclear. In this study, we aimed to present the follow-up data of 94 newborns with a cephalohematoma size of >50 mm and a higher risk of ossification. 

Methods 

This is a single-center, non-randomized, prospective, observational study conducted from May 2014 to May 2019. Records of all newborns with cephalohematoma were reviewed in terms of gender, birth weight, cephalohematoma region, transverse/vertical diameter of the lesion, delivery method, and rate of ossification. 

Results

The girl-to-boy ratio was 53/41, with a mean gestational age of 38.3±1.4 weeks and a mean birth weight of 3,300±800 grams. The mean transverse/vertical diameter of cephalohematoma was 59±9 mm. Cephalohematoma was completely resorbed at the first-month control visits in 72 (76.6%) cases, whereas nine (9.57%) had an ossified cephalohematoma. The ossification was completely or partially resorbed in these at the end of the one-year follow-up. 

Conclusion

Hence, we suggest that an early intervention is not required in the routine treatment of cases with hematomas with a size of >50 mm in size unless otherwise stipulated with clinical indications. 

Infant ossified cephalohematoma: a review of the surgical management and technical update

Cephalohematoma is a subperiosteal collection of blood above the skull. It is associated with operative and prolonged deliveries. In most cases the hematoma spontaneously resolves in a short span of time, usually within one month. In a few cases cephalohematoma can become ossified and require surgical treatment. Traditional belief that ossified cephalohematomas are an exclusively cosmetic issue has been called into question by recent description of EEG anomalies associated to a calcified cephalohematoma. We review relevant surgical literature, and we describe a novel variant of Wong's Radial Cap technique by foregoing healthy bone margin removal, removing the cephalohematoma lamellae in a stepwise fashion and using resorbable plaques for fixation. We furthermore review the rationale, timing and step-by-step execution of the procedure. An exemplary case description is discussed.

Temporal Evolution of Imaging Findings in Ossified Cephalohematoma

BACKGROUND

Cephalohematoma is collection of blood between skull and periosteum that is confined by cranial sutures. Cephalohematomas usually resorb spontaneously within the first month of life; however, if it fails to resolve, ossified cephalohematoma may form.

METHODS

Clinical archiving system and picture archiving and communication system were retrospectively reviewed for cases of birth-related cephalohematoma. Cases of ossified cephalohematomas identified on imaging were retrieved from this subset of patients. Cross-sectional imaging findings in patients with ossified cephalohematomas were evaluated for location, size of the hematoma, and contours of the inner lamella.

RESULTS

Out of 115 cases of cephalohematoma, 7 cases had imaging findings consistent with ossified cephalohematoma. All ossified cephalohematomas were located parietally, with size ranging between 18 and 55 mm and the thickness of the outer rim of calcification ranging between 1.5 and 4.8 mm. The contour of inner lamella in relation to the surrounding normal cranial vault was normal in 5 cases, and inner lamella was depressed in 2 cases.Three patients had follow-up imaging available for demonstration of changes in ossified cephalohematoma. The first case was an 11 day-old boy with a cephalohematoma with no signs of calcification at the time of initial imaging. Follow-up at 2 months of age showed partial regression of hematoma cavity with marked calcification at the hematoma walls. The second case was a 3 month-old boy with ossified cephalohematoma at initial imaging. Follow-up imaging at 7 months of age showed almost total regression of hematoma cavity, and approximation of inner and outer lamella with increased thickness of the cranial vault. The third case was a 1 month-old boy with ossified cephalohematoma at initial imaging that totally resolved without residual increased bone thickness at 21-month follow-up.

CONCLUSION

These 3 cases demonstrate the variability in temporal changes that may occur in ossified cephalohematomas.

Early needle aspiration of large infant cephalohematoma: a safe procedure to avoid esthetic complications

Cephalohematoma is a common pathology in newborns. Observation is the primary treatment for most patients with small uncomplicated cephalohematoma. Conversely, a large cephalohematoma can lead to calcification with unesthetic local deformation or deformational plagiocephaly. The objective of the study was to evaluate the iatrogenic risk associated with early puncture under local anesthesia and oral sucrose. This is a retrospective study of 67 consecutive newborns followed at Montpellier University Hospital, France, between 2010 and 2017. Large cephalohematoma was defined on the basis of the bump projection. Due to the uncertainty of the spontaneous resorption and the risk of calcification after 4 weeks which render the needle aspiration ineffective, puncture was performed between 2 and 4 weeks of life after coagulation evaluation and ultrasound of the skull and scalp. Puncture was performed in 43 boys (64%) and 24 (36%) girls between day 15 and day 30 after birth. The cephalohematoma maximal projection measured by ultrasound ranged from 9 to 13 mm (Q1,Q4) with a median value of 12 mm. No puncture-related complication was recorded during the intervention and at the 1-month follow-up visit.Conclusion: In newborns with large and persistent unesthetic cephalohematoma, puncture under local anesthesia with oral sucrose can be safely proposed between day 15 and day 30 after birth.What is Known:• Infant cephalohematoma is a frequent pathology of newborns, consisting of a traumatic subperiosteal hematoma of the skull. Most cephalohematomas are small and require no treatment because they spontaneously disappear within the first month.• Large and non-resorptive cephalohematomas may have significant esthetic and functional consequences.What is New:• Early puncture under local anesthesia is a safe, effective, and rapid procedure, decreasing the risk of persistent skull deformities.• Puncture can be proposed for newborns with a large (high projection and/or high angle connection) persistent anesthetic cephalohematoma, between day 15 and day 30, before spontaneous calcification.

Sagittal craniosynostosis associated with midline cephalhematoma or vice versa, case report and a review of the literature

INTRODUCTION

Sagittal craniosynostosis associated with midline cephalhematoma is a rare finding. Despite the controversy regarding its etiopathogenesis, this condition represents a clear indication for surgery.

CASE REPORT

We present a case of a 10-week-old boy with an ossified midline vertex cephalhematoma and sagittal craniosynostosis. The child underwent a cephalhematoma excision and minimally invasive non-endoscopic narrow vertex craniectomy, with calvarial vault remodeling followed by 2 weeks use of a cranial orthosis. On 5-month follow-up, mesocephaly was achieved.

CONCLUSION

Our case is well documented with native CT, 3D CT, intraoperative pictures, and 3D head scan imaging. We described our minimally invasive non-endoscopic technique that led to a rapid cranial vault remodeling with reduction of cranial orthosis need. A review of literature focused on surgical techniques is included.

Ossified Cephalhematoma: An Unusual Cause of Calvarial Mass in Infancy

Cephalhematomas occurring in newborn usually resolve within a month. Rarely, they tend to ossify and present as hard scalp swelling. Unless one is aware of this possibility, this condition may be misinterpreted as bony tumor and cause needless apprehension to parents as well as the treating physician. A suspicion that ossified cephalhematoma (OC) could present in such a manner supported by careful history taking and relevant imaging (X-ray/computed tomography) would help in appropriate evaluation of this benign condition. The management of OC is controversial. Occasionally, they undergo spontaneous remodeling. Those with secondary craniosynostosis and/or disfigurement are treated surgically. Simple ossified lesions with no significant cosmetic issues may be conservatively tackled. We report such a case in a 3-month-old child. The other management options are briefly discussed.