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.

Distal ventriculoperitoneal shunt catheter tightly coiled around the valve in the absence of a subgaleal cerebrospinal fluid collection: illustrative case

BACKGROUND Among the known complications of ventriculoperitoneal (VP) shunts, subcutaneous or subgaleal migration of distal catheters is rare. Prior case reports have proposed several risk factors, including inadequate fixation of the shunt device, presence of a large subgaleal space filled with cerebrospinal fluid (CSF), and repetitive flexion/extension movement of the head producing a “windlass effect.” Tight coiling of a distal catheter around the valve without a large subgaleal space has not been reported. OBSERVATIONS The patient was born prematurely and underwent VP shunt placement for posthemorrhagic ventricular dilatation at 3 months of age with reassuring postoperative imaging. At approximately 3 years of age, shunt radiography and head computed tomography unexpectedly showed excess tubing coiled extracranially around the shunt valve. The patient did not exhibit any clinical symptoms of shunt malfunction and underwent an uneventful revision of the VP shunt system. No CSF-filled subgaleal space was observed intraoperatively. LESSONS Distal catheter migration can occur without the clear presence of a subgaleal CSF collection and symptoms of acute hydrocephalus. Appropriate fixation of the shunt system using nonabsorbable stitches is recommended to prevent catheter migration caused by the windlass effect.

Shunt scissors: technical note

OBJECTIVEWhen performing ventriculoperitoneal shunt surgery it is necessary to create a subgaleal pocket that is of sufficient size to accommodate a shunt valve. In most cases the valve is placed over the posterior skull where the galea begins to transition to suboccipital neck fascia. Dense fibrous attachments in this region of the skull make it technically awkward to develop the subgaleal valve pocket using standard scissors and a blunt dissection technique. In this report the authors describe a new device that enables surgeons to create the shunt valve pocket by using a simple semi-sharp dissection technique.METHODSThe authors analyzed the deficiencies of the standard valve pocket dissection technique and designed shunt scissors that address the identified shortcomings. These new scissors allow the surgeon to sharply dissect the subgaleal space by using an efficient hand-closing maneuver.RESULTSStandard surgical scissors were modified to create shunt scissors that were tested on the benchtop and used in the operating room. In all cases the shunt scissors proved easy to use and allowed the efficient and reliable creation of a subgaleal valve pocket in a technically pleasing manner.CONCLUSIONSShunt scissors represent an incremental technical advance in the field of neurosurgical shunt operations.

Large subgaleal hematoma producing turban head in 10 year boy with cerebral palsy: rare case report with review of literature

Subgaleal hematomas (SGHs) are not uncommon. Because the subgaleal space has no anatomical boundaries, SGHs usually involve a large space and are typically limited to the parietal region. Cases of SGHs involving whole of head are relatively rare. In this study we report a rare case of massive enlargement of head after SGH causing severe pain and giving an appearance of turban. A 10 year old, male patient with cerebral palsy presented with progressive enlargement of head attaining a size of turban due to habitual head banging and self-punching overhead. SGH drainage and hematoma aspiration were performed and the patient’s head size was restored.

Reducing surgical site infections following craniotomy: examination of the use of topical vancomycin

OBJECT Although the use of topical vancomycin has been shown to be safe and effective for reducing postoperative infection rates in patients after spine surgery, its use in cranial wounds has not been studied systematically. The authors hypothesized that topical vancomycin, applied in powder form directly to the subgaleal space during closure, would reduce cranial wound infection rates. METHODS A cohort of 150 consecutive patients who underwent craniotomy was studied retrospectively. Seventy-five patients received 1 g of vancomycin powder applied in the subgaleal space at the time of closure. This group was compared with 75 matched-control patients who were accrued over the same time interval and did not receive vancomycin. The primary outcome measure was the presence of surgical site infection within 3 months. Secondary outcome measures included tissue pH from a subgaleal drain and vancomycin levels from the subgaleal space and serum. RESULTS Vancomycin was associated with significantly fewer surgical site infections (1 of 75) than was standard antibiotic prophylaxis alone (5 of 75; p < 0.05). Cultures were positive for typical skin flora species. As expected, local measured vancomycin concentrations peaked immediately after surgery (mean ± SD 499 ± 37 μg/ml) and gradually decreased over 12 hours. Vancomycin in the circulating serum remained undetectable. Subgaleal topical vancomycin was associated with a lower incidence of surgical site infections after craniotomy. The authors attribute this reduction in the infection rate to local vancomycin concentrations well above the minimum inhibitory concentration for antimicrobial efficacy. CONCLUSIONS Topical vancomycin is safe and effective for reducing surgical site infections after craniotomy. These data support the need for a prospective randomized examination of topical vancomycin in the setting of cranial surgery.

Abses subgaleal sebagai komplikasi otitis media supuratif kronis

Latar belakang: Abses subgaleal merupakan salah satu komplikasi yang jarang dari otitis media supuratif kronis. Abses subgaleal ditemukan sekitar 32,4%, namun baru satu kasus mastoiditis dengankomplikasi abses subgaleal pada pasien dewasa yang pernah dilaporkan. Tujuan: Laporan kasus inidimaksudkan untuk mempresentasikan gambaran klinis dan diagnosis, serta penatalaksanaan dari otitismedia supuratif kronis dengan komplikasi abses subgaleal. Kasus: Satu kasus otitis media supuratifkronis dengan komplikasi mastoiditis dan terjadi perluasan infeksi ke ruang subgaleal pada seorang wanitaberumur 21 tahun, gravida 35 minggu. Penatalaksanaan: Dilakukan insisi drainase di temporoparietal,kemudian dilakukan mastoidektomi setelah tindakan terminasi kehamilan. Kesimpulan: Abses subgalealadalah salah satu komplikasi yang jarang terjadi akibat dari otitis media supuratif kronis. Diagnosis secaradini dan penatalaksanan yang tepat akan menentukan tingginya keberhasilan. Kata kunci: Otitis Media Supuratif Kronis, abses subgaleal, gravidaABSTRACT Background: Subgaleal abscess is a rare complication of chronic suppurative otitis media. Subgaleal abscess was found about 32,4%, but only one case of subgaleal abscess as a complication of mastoiditisin adult had been reported. Purpose: To present the clinical and diagnostic findings along with themanagement of subgaleal abscess with mastoidectomy. Case: A case of chronic suppurative otitis mediawith mastoiditis complication and extension into subgaleal space that was found in a 21 years old, 35weeks gravid woman. Management: Drainage incision at temporofacial region and later, mastoidectomyafter childbirth. Conclusion: Subgaleal abscess is one of the rare complications of chronic suppurativeotitis media. Early diagnosis and appropriate treatment will improve the outcome. Keywords: Chronic suppurative otitis media, subgaleal abscess, gravida

Migration and Sub-galeal coiling of distal components of V-P shunt in a 2-year-boy: Does Electrical stimulation as part of physiotherapy is cause or casual association?

The ventriculo-peritoneal (VP) shunt surgery in resource constrained centre still remains, most common form of treatment for hydrocephalus. The V. P. shunt complications can occur along entire course of shunt, distal complications are obstruction of catheter, cerebrospinal fluid ascites, abscess and ulceration of skin. However, total cranial migration and getting coiled in subgaleal space, of peritoneal catheter end is very rare occurrence and is reported in only seven cases as isolated case- report in western literature, further more rare is associated extrusion of ventricular catheter and rarer is subgaleal coiling of both peritoneal and ventricular end. Author reports a rare and unique case of complete migration of peritoneal catheter into subgaleal space in a 2-year old boy associated, with partial extrusion of ventricular end, the child was also given electric stimulation by untrained physiotherapist along the shunt tract, which might have facilitated cranial migration of distal catheter in our case. Pertinent literature is briefly reviewed