Extensive subdural hematoma in full term neonate due to falcine laceration

Abstract

Subdural hematoma in supratentorial location occur due to rupture of bridging veins or by laceration of falx, the latter entity being extremely uncommon cause of hemorrhage in full term new-born neonate who has been delivered by non-instrumental vaginal delivery. Compressive effects on the fetal parietal bones by rigid maternal pelvic structures result in frontal–occipital elongation and vertical or oblique molding. This in turn causes cranio-caudal stretching of both the falx and tentorium. Normally the give-away is at the falcine and tentorial junctions, rarely only falcine laceration can result. Most of massive subdural hematomas due to falx laceration, tentorial laceration or occipital diastasis have a rapid lethal course or patients may have permanent neurological disability. We describe a case of full term neonate who had extensive subdural and parenchymal hemorrhage resulting from falcine tear.

Full text

Extensive subdural hematoma in full term neonate
due to falcine laceration
V. Umamaheswara Reddy
a
, Amit Agrawal
b,*
, H. Suryaprakash
c
,
Vankineni Srikanth
a
, G. Mithilasri
d
a
Department of Radiology, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
b
Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
c
Department of Pediatrics, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
d
Department of Obstetrics and Gynaecology, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra
Pradesh, India
Received 25 October 2014; revised 14 February 2015; accepted 22 February 2015
KEYWORDS
Intracranial hemorrhage;
Subdural hemorrhage;
Falcine laceration
Abstract Subdural hematoma in supratentorial location occur due to rupture of bridging veins or by
laceration of falx, the latter entity being extremely uncommon cause of hemorrhage in full term new-
born neonate who has been delivered by non-instrumental vaginal delivery. Compressive effects on the
fetal parietal bones by rigid maternal pelvic structures result in frontal–occipital elongation and vertical
or oblique molding. This in turn causes cranio-caudal stretching of both the falx and tentorium.
Normally the give-away is at the falcine and tentorial junctions, rarely only falcine laceration can result.
Most of massive subdural hematomas due to falx laceration, tentorial laceration or occipital diastasis
have a rapid lethal course or patients may have permanent neurological disability. We describe a case of
full term neonate who had extensive subdural and parenchymal hemorrhage resulting from falcine tear.
ª2015 The Authors. Production and hosting by Elsevier B.V. on behalf of The Egyptian Pediatric
Association. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
Introduction
Subdural hematomas (SDH) in full term neonates are rare and
they most commonly occur in posterior fossa due to straight
sinus rupture or vein of Galen rupture following tentorial
tears.
1
SDH in supratentorial location occurs due to the
rupture of bridging veins or due to laceration of falx
(Sagittal sinus rupture) is an uncommon cause of hemorrhage
in full term newborn neonate who has been delivered by
non-instrumental vaginal delivery.
1–4
We describe a case of a
neonate who had supratentorial interhemispheric, convexity
subdural hematoma and parenchymal hemorrhage resulting
from falcine laceration.
Case report
A live full term neonate born vaginally in a rural hospital
to a non-consanguineous married couple was brought to our
*Corresponding author at: Department of Neurosurgery, Narayana
Medical College Hospital, Chinthareddypalem, Nellore 524003,
Andhra Pradesh, India. Mobile: +91 8096410032.
E-mail addresses: dramitagrawal@gmail.com,dramit_in@yahoo.
com (A. Agrawal).
Peer review under responsibility of Taibah University.
Egyptian Pediatric Association Gazette (2015) xxx, xxx–xxx
HOSTED BY Contents lists available at ScienceDirect
Egyptian Pediatric Association Gazette
journal homepage: http://ees.elsevier.com/epag
http://dx.doi.org/10.1016/j.epag.2015.02.005
1110-6638 ª2015 The Authors. Production and hosting by Elsevier B.V. on behalf of The Egyptian Pediatric Association.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: Umamaheswara Reddy V et al. Extensive subdural hematoma in full term neonate due to falcine laceration, Egypt Pediatr Assoc
Gazette (2015), http://dx.doi.org/10.1016/j.epag.2015.02.005

hospital in an unresponsive state. During the antenatal period,
mother was not on any drugs, had regular check-ups and an
obstetric ultrasound scan at 28 weeks of gestational period
which did not reveal any abnormality. Mother had prolonged
rupture of membranes, so the baby was delivered with minimal
aids. However, no instrumentation was used during the deliv-
ery process. Baby did not cry immediately after birth & did so
after stimulation. Birth weight was 2756 g, APGAR score was
3 at 1 min and 5 at 5 min. In view of low APGAR score, baby
was referred to our hospital for further management. At
admission, baby was flaccid, had persistent bradycardia and
respiratory efforts were poor with apnoeic spells in between.
Head circumference was 35.5 cm and there was bulging ante-
rior fontanelle. Moro’s reflex was absent. Cranial ultrasound
revealed subdural and parenchymal hematoma with mass
effect. CT scan was performed for further evaluation which
showed massive intracranial bleed in right parafalcine location
which was extending along falx into anterior, posterior sub-
dural spaces and along the tentorium. Small intraparenchymal
hematoma and secondary subarachnoid hemorrhage were also
seen in the right high frontal lobe (Fig. 1). Fetal and maternal
blood investigations were normal and did not reveal any coa-
gulation abnormality. The baby succumbed to severity of the
bleed on the same day.
Discussion
Subdural hematomas result from shearing injuries during
birth.
1,4
These subdural hematomas with or without parenchy-
mal involvement was the commonest cause of neonatal death
in full-term neonates earlier.
5
With improvement of obstetric
care, incidence of traumatic SDHs have reduced signifi-
cantly.
1,2,4–6
Several predisposing factors like maternal (primi-
parity, narrower birth canal, prolonged labor, instrumentation
during delivery) and fetal (macrocephaly, face/brow pre-
sentations) have been described for occurrence of SDH.
1,6
The reported overall incidence of SDH is 8% and it is
10.5% in vaginal deliveries when the neonates were investi-
gated with low-field-strength 0.2T magnet within the first
48 h of their life.
7
However Rooks et al. have reported a higher
incidence of SDH (46%) when they used a higher magnetic-
field-strength 1.5T MR imaging scanner.
8
Compressive effects
on the fetal parietal bones by rigid maternal pelvic structures
result in frontal–occipital elongation and vertical or oblique
molding. This in turn causes cranio-caudal stretching of both
the falx and tentorium. Normally the give-away is at the fal-
cine and tentorial junctions, rarely only falcine laceration can
result. Very rarely following extreme vertical molding, rupture
of the bridging veins results in convexity subdural
hematoma.
1,4,5
In our case our patient had a combination of
interhemispheric and convexity SDH, so we presume that baby
had extreme vertical molding. The clinical presentation of sub-
dural hematomas depends upon the region involved.
Infratentorial massive SDH occurring following tentorial
laceration have more rapid and lethal course than supratentorial
ones.
1,3,4,9
Seizures, stupor, coma, unequal pupils, absent dolls
eye reflex can be associated in infratentorial. SDH occurring
in convexities have the mildest clinical course with patients pre-
senting with no clinical symptoms or irritability or seizures.
Clinical course for supratentorial SDH following falcine lacera-
tion have been sparsely described in the literature. Most of
supratentorial and infratentorial SDHs can be managed con-
servatively. In general, supratentorial SDHs have better prog-
nosis than infratentorial SDHs and combined infra,
supratentorial SDHs.
10
Brouwer et al. in their study described
25.4% mortality rate for supratentorial SDH with parenchymal
involvement.
5
Most of massive subdural hematomas due to falx
laceration, tentorial laceration or occipital diastasis have a rapid
lethal course or patients may have permanent neurological mor-
bidity.
1
Convexity SDHs have better prognosis.
1,4,5
Conclusion
Subdural hematoma occurring due to traumatic lesions has
been decreased significantly by improvement of modern-day
obstetric practices. When encountered, a meticulous history
and laboratory investigations should be done to rule out other
causes of SDH like battered baby syndrome or maternal/fetal
coagulation abnormalities. In emergency setting neonatal neu-
rosonogram performed with fontanelle as window is a useful
screening tool. One should not delay in performing CT scan
in this life threatening condition overruling radiation hazard.
Conflict of interest
None declared.
Figure 1 Plain axial CT sections of brain showing large subdural hematoma with epicenter in right parafalcine location extending
anteriorly and posteriorly along subdural spaces (A), Small component of parenchymal hemorrhage with secondary subarachnoid
hemorrhage present in right high frontal lobe (B) and subdural hemorrhage in the right frontal convexity with mass effect (C).
2 V. Umamaheswara Reddy et al.
Please cite this article in press as: Umamaheswara Reddy V et al. Extensive subdural hematoma in full term neonate due to falcine laceration, Egypt Pediatr Assoc
Gazette (2015), http://dx.doi.org/10.1016/j.epag.2015.02.005

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Extensive subdural hematoma 3
Please cite this article in press as: Umamaheswara Reddy V et al. Extensive subdural hematoma in full term neonate due to falcine laceration, Egypt Pediatr Assoc
Gazette (2015), http://dx.doi.org/10.1016/j.epag.2015.02.005