Abstract

Background: Subgaleal hematoma (SGH) is generally documented within the neonatal period and is rarely reported as a result of trauma or hair braiding in children. While rare, complications of SGH can result in ophthalmoplegia, proptosis, visual deficit, and corneal ulceration secondary to hematoma extension into the orbit. Although conservative treatment is preferential, expanding SGH should be aspirated to reduce complications associated with further expansion.

Case Description: A 12-year-old African-American female with no recent history of trauma presented with a chief complaint of headache along with a 2-day history of enlarging 2–3 cm ballotable bilateral frontal mass. Hematological workup was negative. The patient’s family confirmed a long history of hair braiding. The patient was initially prescribed a period of observation but returned 1-week later with enlarging SGH, necessitating surgical aspiration.

Conclusion: SGH is rare past the neonatal period, but can be found in pediatric and adolescent patients secondary to trauma or hair pulling. Standard workup includes evaluation of the patient’s hematological profile for bleeding or coagulation deficits, as well as evaluation for child abuse. Although most cases of SGH resolve spontaneously over the course of several weeks, close follow-up is recommended. The authors present a case of a 12-year-old female presenting with enlarging subgaleal hemorrhages who underwent surgical aspiration and drainage without recurrence. A literature review was also conducted with 32 pediatric cases identified, 20 of which were related to hair pulling, combing, or braiding. We review the clinical course, imaging characteristics, surgical management, as well as a review of the literature involving subgaleal hemorrhage in pediatric patients and hair pulling.

Keywords: Hair braiding, Subgaleal hematoma, Subgaleal hemorrhage

INTRODUCTION

First described in 1819 as a “false cephalohematoma, and later coined in 1957, subgaleal hematoma (SGH) is a collection of blood in the potential space between the periosteum and galeal aponeurosis, within loose areolar tissue.[ 25 , 36 ] It comprises a fluctuant tissue swelling that crosses suture lines. The majority of the literature on SGH focuses on neonates. Indeed, SGH has been recognized to occur with an incidence of approximately 0.5/1000 births in neonates,[ 35 ] but similar studies are lacking for older children. Although rare, it may result in significant complications and has been associated with minor head trauma, including braiding in older children. It has also been associated with at least one report of pediatric hair pulling by an abusive adult.[ 13 ]

SGH is rare beyond the neonatal period and is typically associated with head trauma resulting in rupture of emissary veins traversing the subgaleal space.[ 36 ] Complications of SGH, though rare, may be serious; the structures of the orbit may be at risk with hematoma extension of blood into the orbit, resulting in proptosis, visual deficit, ophthalmoplegia, and corneal ulceration.[ 22 , 26 , 38 ] A characteristic clinical finding may present as a patient’s inability to open their eyes.[ 1 ] Worse, if there is leakage of blood beyond subgaleal attachment points associated with the zygomatic arch, airway compromise and skin necrosis may result.[ 21 ] Von Willebrand’s disease, the most common inherited bleeding disorder, has also been discovered in patient’s manifesting with subgaleal hemorrhage following hair braiding.[ 28 ]

Recognition of the clinical manifestations and presentation is important for appropriate management. As advocated by other authors,[ 23 ] recognition of this phenomenon can prevent unnecessary interventions and reports to child protective services. This case report describes the case of a 12-year- old female patient who presented with chief complaint of headache and was found to have bilateral frontal ballotable fluid collections consistent with SGH. We conducted a literature review of SGH in the pediatric population and found it to be a rare occurrence, with 32 cases reported.

CASE DESCRIPTION

Our patient was a 12-year-old African-American female presenting with a chief complaint of headache, as well as a 2-day history of enlarging 2–3 cm ballotable bilateral frontal mass. The patient and her family denied any antecedent incidence of trauma, as well as any patient or family history of blood dyscrasias. The patient had an uncomplicated birth history, delivered vaginally at term, with no significant medical history or medication usage. Her family endorsed a long history of hair braiding since the patient was a toddler. With the exception of ballotable mass encompassing the bilateral forehead, the patient’s examination was unremarkable. Computed tomography (CT) of the head [ Figure 1 ] demonstrated subcutaneous hematomas along the bilateral scalp without evidence of underlying fracture or intracranial pathology.

Figure 1:

(a) Axial noncontrast CT head demonstrating bilateral subgaleal fluid collections and (b) sagittal noncontrast CT head demonstrating collections along the frontal and parietal aspects of the calvarium.

Laboratory results demonstrated normal platelet aggregation, Von Willebrand, and Factor 8 and Factor 13 testing. The patient presented without fever, and the rest of her vital signs were unremarkable. The patient was subsequently discharged with follow-up with a pediatric neurosurgery clinic in 2 weeks. One week later, the patient returned with an enlarging subgaleal fluid collection. Magnetic resonance imaging (MRI) of the brain with and without intravenous gadolinium was performed, demonstrating an interval increase in bilateral frontal and parietal scalp hematoma to 2.3 cm, compared to prior noncontrast CT of the head [ Figure 2 ]. Again, no intracranial pathology was identified.

Figure 2:

(a) Axial T2 MRI brain demonstrating bilateral subgaleal fluid collections, enlarged compared to noncontrast CT had a week prior, (b) sagittal T1 flair brain demonstrating collections along the frontal and parietal aspects of the calvarium, and (c) coronal noncontrast T1 MRI of the brain demonstrating bilateral subgaleal hematoma formation.

Although most cases of SGH resolve spontaneously within a few weeks, and therefore, the risk of infections secondary to aspiration and drainage is usually deferred, our patient returned with a worsening clinical course. Therefore, the risks, benefits, and alternatives to bedside drainage were explained to the patient’s family, who decided to proceed.

Given increasing size and overall worsening clinical course of the SGH, the intervention was prompted. A 24 gauge butterfly needle connected to the syringe was inserted into the epidermis in a Z-shaped fashion and slowly advanced with negative pressure at the center of the forehead behind the hairline until a flash of fluid was noted. Only one insertion of the needle was required. Approximately 300 mL of dark, motor oil-like fluid [ Figure 3 ] was aspirated under sterile technique, with a reduction in mass and bogginess of the forehead. Cytological studies demonstrated histiocytes, lymphocytes, and blood without the presence of malignant cells. Gram stain was negative for any organisms as well as negative final cultures. After the drainage, the patient received compression bandages and the family was advised to stop braiding. Finally, the patient resumed regularly scheduled follow-up with both her pediatrician and pediatric neurosurgery clinic without any recurrence to date.

Figure 3:

Approximately 300 mL of dark, motor oil-like fluid was aspirated under sterile technique, with a reduction in mass and bogginess of the forehead.

DISCUSSION

SGH results from the collection of blood between the aponeurosis and the periosteum of the skull. The mechanism likely involves accumulation of blood in the subgaleal layer, where emissary veins drain superficial scalp veins to the dural sinuses.[ 1 ] The previous reports in the literature have cited spontaneous SGH with workup uncovering blood dyscrasias, including impaired platelet aggregation,[ 14 ] Vitamin K deficiency,[ 30 ] or deficient/nonfunctional coagulation factors.[ 4 , 12 , 29 ] Accordingly, a comprehensive hematological workup should ensue when presented with a pediatric patient with a diagnosis of SGH, especially without compression has also been advocated,[ 3 ] as a prelude to surgical intervention. Ultimately, conservative treatment is preferential due to the risk of infection which can spread through the emissary veins to the dural sinuses secondary to more invasive interventions.[ 15 , 36 ] Normally, SGH resolves spontaneously within a 1–5 week period;[ 17 , 23 , 36 ] however, in cases such as the one presented by the authors where further expansion continues, thereby increasing the risk of orbital expansion or calcification of stagnant blood, aspiration should be performed.

A literature review was conducted utilizing Google Scholar and PubMed. Both neonatal (birth up to 4 weeks) and adult cases were excluded from the search. The most comprehensive literature review to date was performed by Scheier et al. and included 16 pediatric cases involving hair pulling or straightening.[ 32 ] In total, 29 pediatric case reports of SGH were identified, comprising 32 pediatric patients in the literature, 20 of which were found to be associated with hair pulling, combing, or braiding.[ 6 , 7 , 8 , 9 , 11 , 16 , 20 , 27 , 31 , 39 ] We also identified several cases secondary to unknown causes or causes other than hair pulling or combing.[ 18 , 19 , 33 , 34 , 37 ]. [ Table 1 ] demonstrates the salient features of these articles, including year of publication, age, and sex of the patients. Our literature review emphasizes that continued growth despite conservative treatment warrants intervention in many cases.[ 2 , 10 , 28 , 36 ] In the large majority of cases where the SGH was limited in size and presented without complications, no intervention was performed; however, frequent follow-up was necessary.[ 5 , 13 , 23 , 24 ]

Table 1:

Demonstrates the salient features of these articles, including year of publication, age, and sex of the patients.

CONCLUSION

SGH is rare past the neonatal period but can be found in pediatric and adolescent patients. Standard workup includes evaluation of the patient’s hematological profile for bleeding or coagulation deficits, as well as evaluation for child abuse. Although most cases of subgaleal hemorrhage resolve spontaneously over the course of several weeks,[ 36 ] close follow-up is recommended. The authors present a case of a 12-year-old female presenting with enlarging subgaleal hemorrhages who underwent surgical aspiration and drainage without recurrence. We review the clinical course, imaging characteristics, surgical management, as well as a review of the literature involving subgaleal hemorrhage in pediatric patients and hair pulling.

Declaration of patient consent

Patient’s consent not required as patients identity is not disclosed or compromised.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1. Bowens JP, Liker K. Subgaleal hemorrhage secondary to child physical abuse in a 4-year-old boy. Pediatr Emerg Care. 2020. p.

2. Cantu RC. Complication of long hair. Lancet. 1971. 1: 350

3. Chen CE, Liao ZZ, Lee YH, Liu CC, Tang CK, Chen YR. Subgaleal hematoma at the contralateral side of scalp trauma in an adult. J Emerg Med. 2017. 53: e85-8

4. Chen SH, Soong WJ, Hsieh YL, Chen SJ, Hwang B. Hemophilia A presenting with intracranial hemorrhage in neonate: A case report. Zhonghua Yi Xue Za Zhi (Taipei). 1994. 54: 62-6

5. Cooling DS, Viccellio P. Massive subgaleal hematoma following minor head trauma. J Emerg Med. 1991. 9: 33-5

6. De Vito A, Mankad K. Our experience of subgaleal haematoma due to hair pulling. Acta Paediatr. 2020. 109: 426

7. Edmondson SJ, Ramman S, Hachach-Haram N, Bisarya K, Fu B, Ong J. Hair today; scalped tomorrow: Massive subgaleal haematoma following sudden hair pulling in an adolescent in the absence of haematological abnormality or skull fracture. J Craniofac Surg. 2016. 27: 1261-2

8. Er A, Çağlar A, Akgül F, Ulusoy E, Karsli E, Yilmaz D. A rare cause of subgaleal hematoma in children: Hair pulling. J Pediatr Emerg Intensive Care Med. 2017. 4: 33-5

9. Faber MM. Massive subgaleal hemorrhage: A hazard of playground swings. Clin Pediatr (Phila). 1976. 15: 384-5

10. Falvo CE, San Filippo JA, Vartany A, Osborn EH. Subgaleal hematoma from hair combing. Pediatrics. 1981. 68: 583-4

11. Fujisawa H, Yonaha H, Oka Y, Uehara M, Nagata Y, Kajiwara K. A marked exophthalmos and corneal ulceration caused by delayed massive expansion of a subgaleal hematoma. Childs Nerv Syst. 2005. 21: 489-92

12. Guirgis MF, Segal WA, Lueder GT. Subperiosteal orbital hemorrhage as initial manifestation of Christmas disease (factor IX deficiency). Am J Ophthalmol. 2002. 133: 584-5

13. Hamlin H. Subgaleal hematoma caused by hair-pull. JAMA. 1968. 204: 339

14. Hutspardol S, Chuansamrit A, Soisamrong A. Spontaneous subgaleal hemorrhage in a girl with impaired adrenaline-induced platelet aggregation. J Med Assoc Thai. 2010. 93: 625-8

15. Karcioglu ZA, Hoehn ME, Lin YP, Walsh J. Ocular involvement after subgaleal hematoma. J AAPOS. 2008. 12: 521-3

16. Kim D, Taragin B. Subgaleal hematoma presenting as a manifestation of factor XIII deficiency. Pediatr Radiol. 2009. 39: 622-4

17. Kirkpatrick JS, Gower DJ, Chauvenet A, Kelly DL. Subgaleal hematoma in a child, without skull fracture. Dev Med Child Neurol. 1986. 28: 511-4

18. Koizumi K, Suzuki S, Utsuki S, Nakahara K, Niki J, Mabuchi I. A case of non-traumatic subgaleal hematoma effectively treated with endovascular surgery. Interv Neuroradiol. 2010. 16: 317-21

19. Lee KS, Bae HG, Yun IG. Bilateral proptosis from a subgaleal hematoma. Case report. J Neurosurg. 1988. 69: 770-1

20. Madhu SV, Agarwal S. Subgaleal haematoma following hair pulling. J Assoc Physicians India. 1990. 38: 955

21. Nichter LS, Bolton LL, Reinisch JF, Sloan GM. Massive subgaleal hematoma resulting in skin compromise and airway obstruction. J Trauma. 1988. 28: 1681-3

22. Okafor BC. Bilateral otorrhagia and orbital hematoma complicating subgaleal hematoma. Ann Otol Rhinol Laryngol. 1984. 93: 237-9

23. Onyeama CO, Lotke M, Edelstein B. Subgaleal hematoma secondary to hair braiding in a 31-month-old child. Pediatr Emerg Care. 2009. 25: 40-1

24. Palmer KM, Olan WJ, Vezina LG, Dubovsky EC. Scalp hematomas in children after hair braiding. Emerg Radiol. 1998. 5: 176-9

25. Plauché WC. Subgaleal hematoma. A complication of instrumental delivery. JAMA. 1980. 244: 1597-8

26. Pomeranz AJ, Ruttum MS, Harris GJ. Subgaleal hematoma with delayed proptosis and corneal ulceration. Ann Emerg Med. 1995. 26: 752-4

27. Puri S, Duff SM, Mueller B, Prendes M, Clark J. Hairpulling causing vision loss: A case report. Orbit. 2019. 38: 162-5

28. Raffini L, Tsarouhas N. Subgaleal hematoma from hair braiding leads to the diagnosis of von Willebrand disease. Pediatr Emerg Care. 2004. 20: 316-8

29. Rohyans JA, Miser AW, Miser JS. Subgaleal hemorrhage in infants with hemophilia: Report of two cases and review of the literature. Pediatrics. 1982. 70: 306-7

30. Ryan CA, Gayle M. Vitamin K deficiency, intracranial hemorrhage, and a subgaleal hematoma: A fatal combination. Pediatr Emerg Care. 1992. 8: 143-5

31. Scheier E, Ben-Ami T, Guri A, Balla U. Subgaleal hematoma from a carnival costume. Isr Med Assoc J. 2019. 21: 422-3

32. Scheier E, Guri A, Balla U. Subgaleal haematoma due to hair pulling: Review of the literature. Acta Paediatr. 2019. 108: 2170-4

33. Seifert D, Püschel K. Subgaleal hematoma in child abuse. Forensic Sci Int. 2006. 157: 131-3

34. Shamji S, Jacoby JL. Massive subgaleal hematoma and clinical suspicion of child abuse. J Am Osteopath Assoc. 2015. 115: 58-60

35. Vacca A. Risk factors associated with subaponeurotic haemorrhage in full-term infants exposed to vacuum extraction. BJOG. 2006. 113: 491

36. Vu TT, Guerrera MF, Hamburger EK, Klein BL. Subgaleal hematoma from hair braiding: Case report and literature review. Pediatr Emerg Care. 2004. 20: 821-3

37. Wajima D, Nakagawa I, Kotani Y, Wada T, Yokota H, Park YS. A case of refractory subgaleal hematoma in adolescence treated with aspiration and endovascular surgery. Acta Neurochir (Wien). 2017. 159: 1565-9

38. Wolter JR, Vanderveen GJ, Wacksman RL. Posttraumatic subgaleal hematoma extending into the orbit as a cause of permanent blindness. J Pediatr Ophthalmol Strabismus. 1978. 15: 151-3

39. Yip CC, McCulley TJ, Kersten RC, Kulwin DR. Proptosis after hair pulling. Ophthalmic Plast Reconstr Surg. 2003. 19: 154-5