Cranial injuries

I. Extracranial Injuries

1. Cephalhematoma

   • It is a sub-periosteal hemorrhage, thus it is limited to the borders of a cranial bone (usually parietal).
   • There is no discoloration of the overlying scalp.
   • It begins to appear after several hours because sub-periosteal bleeding is a slow process.
   • In some cases, there is an underlying linear fracture (detected by X-ray).
   • It resolves gradually and usually leaves an elevated edge.

   Complications:

   • Anemia (blood loss).
   • Hyperbilirubinemia (resorption of the hematoma) may occur with large cephalhematomas.
   • Infection may occur if aspiration is done.

   Management:

   • Usual management is mainly observation (Do not aspirate).
   • Phototherapy may be necessary if blood accumulation is significant leading to jaundice.
   • Rarely anemia can develop needing blood transfusion.
   • The presence of a bleeding disorder should be considered but is rare.
   • Skull radiography or CT scanning is also used if concomitant depressed skull fracture is a possibility.

   Differential Diagnosis:

   • It should be differentiated from:
     • Caput succedaneum.
     • Meningocele (pulsating, increases with crying, x-ray shows a bone defect).
     • Subaponeurotic hemorrhage.

2. Caput Succedaneum
   • This is a diffuse edematous swelling of the scalp, presents at birth, not limited to a bone which resolves in a few days.

CAPUT SUCCEDANEUM	CEPHALHEMATOMA
1. Present at birth on normal vaginal delivery.	1. Appears within a few days after birth on normal or forceps delivery.
2. May lie on sutures, not well defined.	2. Well defined by suture, gradually developing, hard edge.
3. Soft, pits on pressure.	3. soft, elastic but does not pit on pressure.
4. Skin ecchymotic.	4. No skin change.
5. Size largest at birth, gradually subsides within a day.	5. Becomes largest after birth and then disappears within 6-8 weeks to few months.
6. No underlying skull bone fracture.	6. May have underlying skull bone fracture.
7. No treatment required.	7. No treatment required.

Caput Succedaneum
It is a localized swelling or edema which is commonly present on the head of newborn following vaginal delivery. It shows soft pitting when pressure is applied.

3. Subaponeurotic Hemorrhage
   • The whole scalp is swollen and boggy with bluish discoloration.
   • Hemorrhage is in the loose areolar area (under the aponeurosis) i.e., not limited to bone.
   • Clinical picture of shock may be present.

II. Intracranial Hemorrhage

Definition:
Hemorrhage inside the cranial cavity.

Types:

• Outside the brain (epidural, subdural, subarachnoid).
• In the brain ventricles (interventricular).
• In the brain parenchyma (e.g., intracerebral).

The Most Common:

• In preterm → interventricular.
• In full-term → subarachnoid and intracerebral.

Important Causes:

• Instrumental delivery.
• Hypoxia (perinatal, hyaline membrane disease).
• Spontaneous in extreme prematurity.
• Bleeding tendency is a rare cause.

Clinical Manifestations:

• Pallor, cyanosis with irregular breathing, later on jaundice (resorption of concealed blood).

• Lethargy, poor Moro reflex, weak suckling.

• High pitched cry.

• Convulsions, usually tonic.

• Tense bulging anterior fontanel.

• Localizing neurological deficits may occur like ocular palsies, and unequal pupils.

• N.B. Triad of pallor, high-pitched cry, tense bulging ant. fontanel you should suspect intracranial hemorrhage.

Diagnosis:

• Beside the history and clinical picture:
  • Cranial ultrasonography is very useful and as sensitive as the CT scan.
  • A hemorrhagic CSF occurs in subarachnoid hemorrhage.

Complications:

• Death from respiratory failure.
• Obstructive hydrocephalus.
• Cerebral palsy.

Prevention:

• Good maternal and obstetric care.

Treatment: The treatment is a symptomatic one:

• Vitamin K to help coagulation.
• Ventilatory support (if there is respiratory difficulty).
• Phenobarbitone (if there are convulsions).
• Blood transfusion (if there is anemia).
• Treatment of complications like hydrocephalus.