Massive subgaleal hematoma in a 62-year-old man treated with apixaban as a consequence of mild head trauma

Subgaleal hematoma, accumulation of blood in the loose areolar tissue of the subgaleal space of the skull, is considered the most catastrophic complication of instrumental delivery. It is a rare finding in older ages, usually associated with coagulation disorders, severe head trauma leading to skull base fractures and accidental or abusive hair pulling. Complications include periorbital necrotising fasciitis, permanent blindness, infections and, in extreme rare cases, airway obstruction. Most cases of subgaleal hematoma resolve spontaneously, without the need of aspiration or drainage. We present here the case of a 62-year-old male on anticoagulant therapy with apixaban for chronic atrial fibrillation, who came to the emergency department after a car accident suffering from mild head trauma. The patient was complaining of a diffuse headache and physical examination showed a large ecchymosis and edema on the frontal area of the head. His neurological examination was unremarkable. Full-body computed tomography (CT) revealed a fracture of the third right rib. Twelve hours after admission, due to an excessive decrease of hematocrit, a second CT was performed. Although the images didn’t show intracranial hemorrhage or skull base fractures, a large and diffuse hematoma of the subaponeurotic space was observed and the diagnosis of subgaleal hematoma was confirmed. Massive subgaleal hematoma after mild head trauma is rather infrequent. Early diagnosis improves outcomes and can avert serious complications. Therapeutic strategy should be based on the severity of each case. In our case, conservative treatment appeared to be a valid alternative to surgery, as hematoma resolved spontaneously within 10 days. It is noteworthy that the use of anticoagulation is the only evident factor that could have been the precipitating factor for the development of the hematoma in our patient.

Point-of-care Ultrasound to Distinguish Subgaleal and Cephalohematoma: Case Report

Introduction: Cephalohematomas generally do not pose a significant risk to the patient and resolve spontaneously. Conversely, a subgaleal hematoma is a rare but more serious condition. While it may be challenging to make this diagnostic distinction based on a physical examination alone, the findings that differentiate these two conditions can be appreciated on point-of-care ultrasound (POCUS). We describe two pediatric patient cases where POCUS was used to distinguish between a subgaleal hematoma and a cephalohematoma. Case Reports: We describe one case of a 14-month-old male brought to the pediatric emergency department (PED) with concern for head injury. A POCUS examination revealed a large fluid collection that did not cross the sagittal suture. Thus, the hematoma was more consistent with a cephalohematoma and less compatible with a subgaleal hematoma. Given these findings, further emergent imaging was deferred in the PED and the patient was kept for observation. In the second case an 8-week-old male presented with suspected swelling over the right parietal region. A POCUS examination was performed, which demonstrated an extensive, simple fluid collection that extended across the suture line, making it more concerning for a subgaleal hematoma. Given the heightened suspicion for a subgaleal hematoma, the patient was admitted for further imaging and evaluation. Conclusion: Point-of-care ultrasound can be used to help differentiate between a subgaleal hematoma and a cephalohematoma to risk-stratify patients and determine the need for further imaging.

THE APPLICATION OF NPWT TECHNIQUE IN TREATMENT OF AN EXTENSIVE INFECTED SUBGALEAL HEMATOMA IN AN ADULT

Negative pressure wound therapy (NPWT) has been proven to be one of the most effective techniques in the treatment of severely infected wounds of various origins and localizations. At the same time, the prospects for its application are constantly expanding. This clinical observation demonstrates the use of NPWT in the treatment of an adult patient hospitalized in severe condition with a picture of extensive post-traumatic infected subgaleal hematoma. The development of a generalized suppurative purulent process was contributed both by the patient’s late request for medical help (18^th day after the injury) and, as a consequence, the lack of primary surgical treatment of the scalp soft tissue injury, as well as the anatomical features of this area. The magnetic resonance tomography as instrumental examination methods played a significant role in the diagnosis of complications in addition to clinical data. Medical tactics was based on the surgical treatment of the infected focus, the application of antibacterial therapy, taking into consideration the isolated microbial flora (Streptococcus pyogenes). To eliminate severe inflammatory changes in the tissues and to reduce the size of the vast subaponeurotic cavity, NPWT technique was applied, which made it possible in short time to prepare a postoperative wound for surgical closure. The early secondary suturing at the final stage of treatment allowed obtaining a good result.

Brain skull traumatism: a neurological approach

Introduction: Brain Cranium Trauma (TBI) is defined as any traumatic injury that causes an anatomical lesion or functional impairment of the scalp, skull, meninges, brain or its vessels. In the set of injuries from external causes, the TBI stands out in terms of magnitude and, above all, as a cause of death and disability. Objectives: Demonstrate basic and current concepts in relation to the pathophysiology, diagnosis and treatment of TBI. Methods: The present work is a narrative review of the literature in the PubMed, SciELO and CNBI databases. As search criteria, the following keywords were used: “traumatic brain injury”; “Semiology”; “Neurology” and articles, which were limited to a specific period of 5 years. Exclusion: case reports and inclusion: 12 articles. Results: The main causes of TBI are car accidents, falls, being run over, aggression and sports activities. It was observed that most victims of TBI have subgaleal hematoma (HS), followed by fractures. In mild and moderate TBI, the appearance of HS is more prevalent, 48.5%. In TBI, severe, the incidence of subarachnoid hemorrhage predominates with 71.1% of cases in the first study and 62.5% in the second. Conclusion: The main group affected by TCE are mostly male and young, this predominance is related to the increase in violence with firearms, alcoholism and high speeds in traffic. The elderly group is at risk due to their susceptibility to falls. Children are also prone due to lack of motor coordination, resulting in acidentes.

Large subgaleal hematoma caused by valproic acid: a case report

Introdução: Valproic acid (VPA), used to treat epilepsy, may present hematological abnormalities as complications. One such example is bleeding associated with trauma. We herein report a case about large subgaleal hemorrhage that occurred after a mild head trauma in a child following VPA administration. Case Report: A 12-year-old female child diagnosed with Rett Syndrome had difficulty in controlling epilepsy and was taking 50 mg/kg/day VPA. After suffering from a mild head trauma, a large subgaleal hematoma was evidenced on Computed Tomography(CT) scan of head. Surgical intervention was performed, with drainage of the hematoma, and the patient showed progression. Discussion: The incidence of coagulopathy related to VPA is 4%, and thrombocytopenia is the most common coagulation disorder. Hemorrhagic complications can occur regardless of the plasma levels or duration of treatment. In VPA therapy, the side effects should be considered, particularly hematological abnormalities. In our case, an unusual hemorrhagic complication (subgaleal hematoma) was reported, with good surgical resolution of the pathology.