Intrauterine Chronic Subdural Hematoma John T. MacDonald, MD;
Raphael Weitz, MD; Phyllis
\s=b\We discuss a newborn delivered by elective cesarean section who had macrocephaly with severe anemia. The anemia was corrected by exchange transfusion, and the infant, at first, appeared stable but manifested poor feeding and seizures. Transillumination of the skull was negative, although the anterior fontanel was tense. Computerized tomography demonstrated mild hydrocephalus and suggested subdural fluid. Bilateral subdural taps yielded fluid typical for chronic subdural hematoma. To our knowledge, this is the first documented case of intrauterine subdural hematoma developing in the absence of trauma. An analogy is made to the pathogenesis of subdural hematoma after rapid decompression of the ventricular system by shunting procedures for obstructive hydrocephalus. (Arch Neurol 34:777-778, 1977)
K.
Sher, MD at birth is
Macrocephalyhydrocephalus.1usually due to
megalencephaly is an possibility of
cause.2 The
True occasional
an
acute
or
subacute subdural hematoma, how¬ ever, is usually not entertained unless after a difficult delivery, an infant is found to have a progressively enlarg¬ ing head.3 This report describes an infant with bilateral chronic subdural hematomas that were present prior to delivery and responsible for macro¬ cephaly at birth. Successful treatment was accomplished by repeated needle
drainage.
A second male infant
symmetrically depressed. laboratory data showed the following values: serum calcium, 9.0 mg/
were
Initial
REPORT OF A CASE was
born to
a
25-
after an uncomplicated pregnancy. Because of previous cesarean section, the pregnancy was terminated by an elective cesarean section. Minor placental bleeding was quickly controlled and the infant was delivered without difficulty. Birth weight was 2,400 gm, with an esti¬ mated gestational age of 38 weeks. Apgar scores at one and five minutes were 2 and 6. The infant was macrocephalic and very pale, with grunting respirations that
year-old
tocrit value was 8.5%. An immediate trans¬ fusion elevated it to 34%. After transfu¬ sion, the infant was lethargic, with stable vital signs. A flow murmur was audible at the left cardiac border and the lungs were clear. Mild hepatomegaly was noted. The head circumference was 36.6 cm, large in comparison to the body size, with a box-shaped appearance due to biparietal prominence and frontal bossing. The ante¬ rior fontanel was 8 8 cm and tense. The posterior fontanel was 2 3 cm and full. All sutures were widely separated. Transillumination of the entire skull, including the fontanels was negative. The Moro reflex, muscle tonus, and stretch reflexes
woman
improved after suctioning, warming, and administration of 40% oxygen. The hema-
for publication July 11, 1977. From the Department of Neurology, University of Miami Medical Center, Miami. Reprint requests to 4440 Sheridan St, Emerald Hills Medical Square, Hollywood, FL 33021
Accepted
(Dr Sher).
Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 06/11/2015
100
ml; blood glucose, 70 mg/100 ml; blood
pH, 7.42; serum osmolality, 292 mOsm/kg; and platelets, 165,000/cu mm. Prothrombin time was 100% of control and partial prothrombin time was 45 seconds. Umbil¬ ical cord IgM was 0 mg/100 ml. The serum amino acid screening test was negative, as was urine for cytomegalic inclusion bodies. A VDRL was nonreactive. The baby was placed in a warmed isolette and intravenous dextrose solution and 35% oxygen were administered. Grad¬ ual improvement in alertness, muscle tonus, and reflexes was noted in the next three days. The serum bilirubin level increased to 18.4 mg/100 ml by the fourth day, and phototherapy was instituted. By the fifth day, the infant was alert, had a good cry, but continued to feed poorly. On the 8th day, the infant had episodes
rhythmic, abnormal posturing of the extremities, with lip smacking and lid flut¬ tering. An EEG demonstrated bilateral paroxysmal activity, and phénobarbital treatment was given. No further seizures of
occurred. The head circumference was unchanged and transillumination was again negative. The anterior fontanel became more tense. Computerized tomographic (CT) scan of the brain showed mild symmetric ventricular enlargement, with extensive subdural fluid on both sides. Subdural taps were done through the coronal sutures and 14 ml of extremely thick, dark-brown fluid was removed from each side. The anterior fontanel became depressed and the head circumference was reduced to 35.2 cm. The subdural fluid showed a protein content of 4,300 mg/100 ml, an RBC count of 269,000/cu mm, and an WBC count of 1,825 (75% mononuclear
cells). On the 10th day, 13 ml of similar fluid was removed. The hematocrit value re¬ mained at 35%, but later, one more blood transfusion was required. A third subdural tap was done on the 13th day, with removal of 12 ml of brown viscous fluid. The baby became more alert, with improved feeding and adequate weight gain. The head circumference was stable at 34.5 cm after the last subdural drainage, and the fonta¬ nels were soft. Electroencephalography showed decreased paroxysmal activity. A CT scan at 21 days demonstrated slight symmetric ventricular enlargement, with no evidence of the previous subdural collections. The infant was discharged on phénobarbital therapy and regular formula
at three weeks of age. Examination at six months of age disclosed an alert, normally responsive 6.4-
kg infant. Head control was normal, although the infant was mildly and diffusely hypotonie and had bilaterally brisk reflexes without pathological re¬ flexes. Head circumference was 42 cm, and the anterior fontanel was soft. No further seizures were reported, and the infant was maintained on phénobarbital treatment.
COMMENT
To our knowledge, there are no previous reports of chronic subdural
hematomas present at birth. While several authors have documented subdural hematomas during the neo¬ natal period, the hematomas have been invariably ascribed to traumatic
delivery, postnatal bleeding diathesis, and, occasionally, as a complication of shunting procedures for hydrocepha¬
lus.4"6 The infant described here was born by elective cesarean section without head trauma. The mother could not recall prenatal injury. Macrocephaly was present at birth, and laboratory data were compatible with severe chronic anemia. The evacuated fluid was characteristic of chronic subdural hematoma. In retrospect, the negative transillumination of the skull in combina¬ tion with the biparietal bossing was of diagnostic significance. Only three
bilateral subdural taps were per¬ formed, since the baby was improving without abnormal increase in head size. It is our contention that bilateral subdural hematomas had been present in utero for some time prior to deliv¬ ery. Any of several factors might be involved in the pathogenesis. Perhaps significant abdominal trauma during pregnancy was not recalled. It may be that the subdural collections occurred first and that the ventricular enlarge¬ ment was the result of secondary
communicating hydrocephalus. An¬ other supposition is that the mild
ventricular dilation may offer an explanation for this unusual oc¬ currence. The pathogenesis of the chronic subdural hematomas in our patient may be similar to that which operates after shunting procedures for obstructive hydrocephalus. In these cases, it has been postulated that retraction of the cerebral hemi¬
spheres postoperatively causes tear¬ ing of bridging veins from the superior sagital sinus.6-7 Perhaps in our patient, an intermittent aqueductal obstruction had resulted in intrauterine hydrocephalus that had remitted suddenly with internal de¬ compression, tearing of bridging veins, and consequent subdural hema¬ tomas.
References 1. Menkes JH: Textbook of Child Neurology. Philadelphia, Lea & Febiger, 1974, pp 152-168. 2. DeMyer W: Megalencephaly in children. Neurology 22:634-643, 1972. 3. Abroms IF, McLennan JE, Mendell F: Acute neonatal subdural hematoma following breech
delivery. Am J Dis Child 131:192-194, 1977. 4. Craig WS: Intracranial hemorrhage in
6. Anderson FM: Subdural hematoma: A the
newborn. Arch Dis Child 13:89-124, 1938. 5. Schipke R, Riege D, Scoville WB: Acute subdural hemorrhage at birth. Pediatrics 14:468x=req-\ 473, 1954.
Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 06/11/2015
com-
plication of operation for hydrocephalus. Pediatrics 10:11-17, 1952. 7. Friede RL: Developmental Neuropathology. New York, Springer-Verlag, 1975, pp 191-192.
Raphael Weitz, MD; Phyllis
\s=b\We discuss a newborn delivered by elective cesarean section who had macrocephaly with severe anemia. The anemia was corrected by exchange transfusion, and the infant, at first, appeared stable but manifested poor feeding and seizures. Transillumination of the skull was negative, although the anterior fontanel was tense. Computerized tomography demonstrated mild hydrocephalus and suggested subdural fluid. Bilateral subdural taps yielded fluid typical for chronic subdural hematoma. To our knowledge, this is the first documented case of intrauterine subdural hematoma developing in the absence of trauma. An analogy is made to the pathogenesis of subdural hematoma after rapid decompression of the ventricular system by shunting procedures for obstructive hydrocephalus. (Arch Neurol 34:777-778, 1977)
K.
Sher, MD at birth is
Macrocephalyhydrocephalus.1usually due to
megalencephaly is an possibility of
cause.2 The
True occasional
an
acute
or
subacute subdural hematoma, how¬ ever, is usually not entertained unless after a difficult delivery, an infant is found to have a progressively enlarg¬ ing head.3 This report describes an infant with bilateral chronic subdural hematomas that were present prior to delivery and responsible for macro¬ cephaly at birth. Successful treatment was accomplished by repeated needle
drainage.
A second male infant
symmetrically depressed. laboratory data showed the following values: serum calcium, 9.0 mg/
were
Initial
REPORT OF A CASE was
born to
a
25-
after an uncomplicated pregnancy. Because of previous cesarean section, the pregnancy was terminated by an elective cesarean section. Minor placental bleeding was quickly controlled and the infant was delivered without difficulty. Birth weight was 2,400 gm, with an esti¬ mated gestational age of 38 weeks. Apgar scores at one and five minutes were 2 and 6. The infant was macrocephalic and very pale, with grunting respirations that
year-old
tocrit value was 8.5%. An immediate trans¬ fusion elevated it to 34%. After transfu¬ sion, the infant was lethargic, with stable vital signs. A flow murmur was audible at the left cardiac border and the lungs were clear. Mild hepatomegaly was noted. The head circumference was 36.6 cm, large in comparison to the body size, with a box-shaped appearance due to biparietal prominence and frontal bossing. The ante¬ rior fontanel was 8 8 cm and tense. The posterior fontanel was 2 3 cm and full. All sutures were widely separated. Transillumination of the entire skull, including the fontanels was negative. The Moro reflex, muscle tonus, and stretch reflexes
woman
improved after suctioning, warming, and administration of 40% oxygen. The hema-
for publication July 11, 1977. From the Department of Neurology, University of Miami Medical Center, Miami. Reprint requests to 4440 Sheridan St, Emerald Hills Medical Square, Hollywood, FL 33021
Accepted
(Dr Sher).
Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 06/11/2015
100
ml; blood glucose, 70 mg/100 ml; blood
pH, 7.42; serum osmolality, 292 mOsm/kg; and platelets, 165,000/cu mm. Prothrombin time was 100% of control and partial prothrombin time was 45 seconds. Umbil¬ ical cord IgM was 0 mg/100 ml. The serum amino acid screening test was negative, as was urine for cytomegalic inclusion bodies. A VDRL was nonreactive. The baby was placed in a warmed isolette and intravenous dextrose solution and 35% oxygen were administered. Grad¬ ual improvement in alertness, muscle tonus, and reflexes was noted in the next three days. The serum bilirubin level increased to 18.4 mg/100 ml by the fourth day, and phototherapy was instituted. By the fifth day, the infant was alert, had a good cry, but continued to feed poorly. On the 8th day, the infant had episodes
rhythmic, abnormal posturing of the extremities, with lip smacking and lid flut¬ tering. An EEG demonstrated bilateral paroxysmal activity, and phénobarbital treatment was given. No further seizures of
occurred. The head circumference was unchanged and transillumination was again negative. The anterior fontanel became more tense. Computerized tomographic (CT) scan of the brain showed mild symmetric ventricular enlargement, with extensive subdural fluid on both sides. Subdural taps were done through the coronal sutures and 14 ml of extremely thick, dark-brown fluid was removed from each side. The anterior fontanel became depressed and the head circumference was reduced to 35.2 cm. The subdural fluid showed a protein content of 4,300 mg/100 ml, an RBC count of 269,000/cu mm, and an WBC count of 1,825 (75% mononuclear
cells). On the 10th day, 13 ml of similar fluid was removed. The hematocrit value re¬ mained at 35%, but later, one more blood transfusion was required. A third subdural tap was done on the 13th day, with removal of 12 ml of brown viscous fluid. The baby became more alert, with improved feeding and adequate weight gain. The head circumference was stable at 34.5 cm after the last subdural drainage, and the fonta¬ nels were soft. Electroencephalography showed decreased paroxysmal activity. A CT scan at 21 days demonstrated slight symmetric ventricular enlargement, with no evidence of the previous subdural collections. The infant was discharged on phénobarbital therapy and regular formula
at three weeks of age. Examination at six months of age disclosed an alert, normally responsive 6.4-
kg infant. Head control was normal, although the infant was mildly and diffusely hypotonie and had bilaterally brisk reflexes without pathological re¬ flexes. Head circumference was 42 cm, and the anterior fontanel was soft. No further seizures were reported, and the infant was maintained on phénobarbital treatment.
COMMENT
To our knowledge, there are no previous reports of chronic subdural
hematomas present at birth. While several authors have documented subdural hematomas during the neo¬ natal period, the hematomas have been invariably ascribed to traumatic
delivery, postnatal bleeding diathesis, and, occasionally, as a complication of shunting procedures for hydrocepha¬
lus.4"6 The infant described here was born by elective cesarean section without head trauma. The mother could not recall prenatal injury. Macrocephaly was present at birth, and laboratory data were compatible with severe chronic anemia. The evacuated fluid was characteristic of chronic subdural hematoma. In retrospect, the negative transillumination of the skull in combina¬ tion with the biparietal bossing was of diagnostic significance. Only three
bilateral subdural taps were per¬ formed, since the baby was improving without abnormal increase in head size. It is our contention that bilateral subdural hematomas had been present in utero for some time prior to deliv¬ ery. Any of several factors might be involved in the pathogenesis. Perhaps significant abdominal trauma during pregnancy was not recalled. It may be that the subdural collections occurred first and that the ventricular enlarge¬ ment was the result of secondary
communicating hydrocephalus. An¬ other supposition is that the mild
ventricular dilation may offer an explanation for this unusual oc¬ currence. The pathogenesis of the chronic subdural hematomas in our patient may be similar to that which operates after shunting procedures for obstructive hydrocephalus. In these cases, it has been postulated that retraction of the cerebral hemi¬
spheres postoperatively causes tear¬ ing of bridging veins from the superior sagital sinus.6-7 Perhaps in our patient, an intermittent aqueductal obstruction had resulted in intrauterine hydrocephalus that had remitted suddenly with internal de¬ compression, tearing of bridging veins, and consequent subdural hema¬ tomas.
References 1. Menkes JH: Textbook of Child Neurology. Philadelphia, Lea & Febiger, 1974, pp 152-168. 2. DeMyer W: Megalencephaly in children. Neurology 22:634-643, 1972. 3. Abroms IF, McLennan JE, Mendell F: Acute neonatal subdural hematoma following breech
delivery. Am J Dis Child 131:192-194, 1977. 4. Craig WS: Intracranial hemorrhage in
6. Anderson FM: Subdural hematoma: A the
newborn. Arch Dis Child 13:89-124, 1938. 5. Schipke R, Riege D, Scoville WB: Acute subdural hemorrhage at birth. Pediatrics 14:468x=req-\ 473, 1954.
Downloaded From: http://archneur.jamanetwork.com/ by a New York University User on 06/11/2015
com-
plication of operation for hydrocephalus. Pediatrics 10:11-17, 1952. 7. Friede RL: Developmental Neuropathology. New York, Springer-Verlag, 1975, pp 191-192.
![[Chronic subdural hematoma].](/assets/img/hold.png)
