- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
Anthony L. Petraglia
Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
DOI:10.4103/2152-7806.66622© 2010 Petraglia AL. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Petraglia AL, Moravan MJ, Marky AH, Silberstein HJ. Delayed sub-aponeurotic fluid collections in infancy: Three cases and a review of the literature. Surg Neurol Int 21-Jul-2010;1:34
How to cite this URL: Petraglia AL, Moravan MJ, Marky AH, Silberstein HJ. Delayed sub-aponeurotic fluid collections in infancy: Three cases and a review of the literature. Surg Neurol Int 21-Jul-2010;1:34. Available from: http://sni.wpengine.com/surgicalint_articles/delayed-sub-aponeurotic-fluid-collections-in-infancy-three-cases-and-a-review-of-the-literature/
Background:Sub-aponeurotic fluid collections (SFCs) in the neonatal period are poorly described in the literature. We describe the occurrence, possible etiologies and treatment of sub-aponeurotic fluid collections following the neonatal period.
Case Description:We present 3 cases of previously healthy children who developed soft, fluctuant, extracranial masses several weeks after birth. All 3 children were seen by a pediatric neurosurgeon after parents noticed scalp masses between 5 and 9 weeks of age. All 3 children were found to be otherwise healthy. Two of the children were born via C-section and 1 child was born vaginally. The vaginal delivery was described as difficult and utilized vacuum assist. Scalp electrodes were placed in all 3 children for intensive monitoring during labor. These children received plain skull x-rays to assess for abnormalities, and 2 of the children underwent a non-contrast brain CT scan to better characterize the fluid collection. Plain x-rays and CT scans showed no abnormalities of the skull or ventricles. In both patients who underwent a CT scan, a soft tissue prominence was noted with a Hounsfield unit similar to water. All cases resolved between 5 and 9 weeks after initial presentation, with no long-term sequelae.
Conclusion:SFCs presenting after the neonatal period are usually associated with benign soft tissue swellings. Use of fetal scalp electrodes has been shown to cause cerebrospinal fluid (CSF) leakage in the neonatal period and may result in delayed SFC. This condition is benign, and the recommended course of treatment is conservative management.
Keywords: CSF leak, fetal scalp electrodes, sub-aponeurotic fluid collection
Sub-aponeurotic fluid collections (SFCs) of CSF have been previously described; however, the number of cases in the literature remains small. Scalp swelling in the neonatal period is common, and causes can include cephalohematoma, caput succedeneum, sub-aponeurotic hemorrhage and SFCs.[
Three children, born at term, with scalp swelling were referred to the neurosurgery department for further evaluation. All 3 children were found to have sub-aponeurotic fluid collections. The clinical and imaging findings, method of treatment and outcome were recorded. Obstetric history and neonatal history were obtained retrospectively.
Clinical features are displayed in
Upon clinical examination by a pediatric neurosurgeon at URMC, all 3 children were found to be awake and alert, no abnormalities of the skull were found on palpation and all children were reaching appropriate developmental milestones. Exams revealed non-tender, soft compressible and fluctuant scalp masses in all patients [Figures
Skull radiographs in 2 of the 3 patients demonstrated well-circumscribed smooth masses overlying the skull. In the third case, anteroposterior (AP) and lateral views of the skull showed no soft tissue abnormality, despite its gross appearance on physical exam. In all 3 patients, skull radiographs showed no signs of skull fracture, abnormal areas of lucency or sclerosis [
Computed tomography (CT) scans of the brain without contrast were obtained for 2 of the patients. The CT scans better characterized the soft tissue swellings in both patients and confirmed the skull radiograph findings [
The etiology of SFCs remains largely uncertain.[
Based on the imaging data and clinical exam, the scalp swellings in our patients were consistent with CSF. Our data neither support nor disprove previous hypotheses that SFCs are related to traumatic labor,[
The unique aspect of SFC in this case series is the use of FSEs in all 3 patients. Past studies have identified FSEs as a known cause of CSF leakage in the neonate,[
Although imaging findings can aid in differentiating these CSF collections from other etiologies of scalp swelling, the diagnosis is primarily a clinical one. These CSF collections are fluctuant and do not tend to cause periosteal ridging as seen with cephalohematomas. Aspiration of these lesions has proven unnecessary and carries the potential risk of infection.[
The authors acknowledge that this phenomenon is a likely common presentation in the pediatric neurosurgery clinic; however, with only 12 cases of SFC described in the literature, all of which are from European countries, it is important that clinicians are aware of this and are prepared to manage patients appropriately. Taking into account previous published accounts of SFC, and our own experiences, management of sub-aponeurotic fluid collections should be conservative and these collections do not need to be aspirated, as most will spontaneously resolve.
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