Youmans Neurological Surgery

1. Birth Head Trauma
Youmans chapter 212
Avinash Mohan, Robin M. Bowman
3/06/59

2. Outline
• Incidence and risk factor
• Scalp injury
• Skull fractures
• Intracranial hemorrhage

3. Incidence and risk factor
• Fracture, paralysis, laceration
• 1 and 11.7 per every 1000 to 2000 live birth
• Perinatal death secondary to birth trauma : 1 in 1000 to
2000
• Risk factor : macrosomia(> 4000 gms), growth
retardation, preterm labor, breech presentation,
multiparity
• Mode of delivery
– Vaginal delivery with forceps or vacuum extractor : higher rate of
trauma
– Cesarean section : lower rate of birth trauma

4. Scalp injury

5. Caput succedaneum
• Most common,normally at vertex
• Superficial serosanguineous collection that crosses
suture lines
• Edema of the outer layer of the scalp,collection in the
portion of the scalp that lead way down the birth canal
• Associated with the use of vacuum extraction
• Immediately after birth
• Management
– Resolve in 24 hr

6. Subgaleal hematoma
• Most life-threatening
• Hemorrhage beneath aponeurosis of scalp that crosses
suture lines
• Galea aponeurotica extend from the supra orbital rims to
the hairline posteriorly and laterally to the level of the
ears  potential space can easily accommodate the
entire blood volume of neonate
• Risk for development
– Coagulation defect
– Vitamin K deficiency
– Difficult delivery in which vacuum extraction is used

7. Subgaleal hematoma
• Clinical diagnosis : identifying a fluctuant scalp mass that
extends beyond the cranial sutures and is more sizable
than caput succedaneum
• Easily identified on CT
• Management
– Emergency blood transfusion and coagulation factor

8. Cephalohematoma
• 1-2% of all birth
• Accumulation of blood between the periosteum and
bone,therefore the cranial sutures limit its expansion
• Forces of labor acting on the neonatal head shear the
periosteum away from the bone
• Most common location : parietal region
• No clinical significant
• Management
– Resolve spontaneously within a few weeks to month

9. Cephalohematoma
• Complication :
– Infection, lead to osteomyelitis, meningitis or sepsis
• Most common organiasm : E.Coli
• Usually occurs within 3 wks
• Rx : diasnostic tap or open irrigation and drainage
– Hyperbilirubinemia
– Anemia
– hemodynamic instability

10. Skull fracture
• Cause : narrow pelvic passage or pressure against the
promontory of the sacrum by forceps and vacuum
extractor
• CT for rule out an associated intracranial hemorrhage
• 3 type
– Linear skull fracture
– Depressed skull fractures
– Occipital osteodiastasis

11. Linear skull fracture
• 5-25%, associated with cephalohematoma
• Most common : parietal bone
• CT for rule out an EDH
• Management
• Usually heal within 2 to 3 months
• require only a follow-up skull radiograph to rule out a
growing skull fracture
• Growing skull fracture(posttraumatic leptomeningeal
cyst)
• Fracture lines that widening with time and dural tear
• Cyst cause mass effect with neurological deficit

12. Depress or Ping-Pong skull fracture
• Unique to newborn period,because of thin,pliable nature
of a newborn’s skull
• CT scan
• Often improve and become elevated spontaneously
• Indication for surgery
• bone fragement in the cerebrum
• neurological deficit with or without increase intracranial pressure
• Management
• Elevated by sliding a Penfield dissector
• Care must be taken to completelt strip the dura away from the
suture line and under the fracture
• Should not use intact skull for fulcrum

13. Depress or Ping-Pong skull fracture

14. Occipital osteodiastasis
• Difficult delivery,forceps breech delivery
• Synchondrosis opens between the squamous part and
the condylar portion of the occipital bone
• Increase tentorial and falcine tears, with damage to
draining venous structures

15. Occipital osteodiastasis

16. Intracranial hemorrhage
• Most serious complication
• Initial symptoms related to mass effect,especially for
lesion in the posterior fossa
• Perinatal seizure
• CT imaging
• Type
– Epidural hematoma
– Subdural hematoma
– Subarachnoid hemorrhage
– Intraparenchymal hematoma

17. Epidural hematoma
• Associated with skull fracture in 30-40% of case
• Skull may distort without fracture,thereby tearing the
dura away from the under surface of cranium
• Bleeding form emissary dural veins or from branch of
middle meningeal artery
• May initially go undetected,until increase ICP
• Sign of increase ICP
– Full fontanelle
– Increase head circumference
– Brainstem compression with pupillary changes

18. Epidural hematoma
• Management
– Less than 1 cm thick : conservative with series CT
– Open craniotomy with evacuation of the hematoma

19. Subdural hematoma
• Secondary to rupture cortical vein
• Excessive vertical molding of the head, elongation and
distortion of the head
• Posterior fossa subdural hematoma(PFSH)
– Exhibit symptoms withing 24 hr after birth
– Most common initial symptom : irritability, lethargy, a
full fontanelle, hypotonia, poor oral intake and
unstable vital sign
– CT scan

20. Subdural hematoma
– Management
• Aggressive drainage : cause sign of IICP or brain stem
compression
• Difficult to gain access
• Dissolve spontaneous time
• Hydrocephalus,follow

21. Subdural hematoma

22. Intraparenchymal hemorrhage
• Usually occur in conjunction with SDH
• Due to mechanical deformation of the intraoccipital
synchondrosis during delivery when the lower lip of
squamous portion of the occipital bone is depressed and
cause cerebellar contusion or laceration
• Associated with forceps or breech delivery
• Symptom similar to SDH
• CT scan
• Management
– Small clot : conservative
– Large ones causing sign of brain or brain stem compression
require surgical evacuation

23. Thank you