A full-term newborn delivered via vacuum-assisted vaginal delivery has an apneic event associated with central cyanosis and lip twitching at six hours after birth. The initial laboratory evaluation shows a normal point-of-care glucose level, mild metabolic acidosis, normal blood cell indices, and normal coagulation studies. Blood and cerebrospinal fluid cultures are pending. As shown in figure 1, brain magnetic resonance imaging (MRI) is obtained.
Figure 1. T2-weighted image of brain MRI of the neonate: The vignette reveals large intracranial and extra-axial fluid collections. Image adapted from: Pollack R, Lamichhane A. Term infant with apnea. Neoreviews. 2023;24(10):e670–6731
Of the following, which anatomic location is affected in this neonate?
- Beneath the periosteum
- Beneath the pia mater
- Between the periosteum and gala aponeurotica
- Between the skin and gala aponeurotica, above the periosteum
- Between the skull and dura mater
Answer: B. Beneath the pia mater
Explanation:
The presentation of apnea and seizures in a term neonate soon after birth should raise suspicion for serious etiologies, including intracranial hemorrhage, cerebrovascular accident, infection, central nervous system malformations, and metabolic causes. This should prompt further investigation with head ultrasonography or an MRI if the patient is clinically stable. The neonate in this vignette demonstrates apnea and seizures with characteristic brain MRI findings (T2-weighted image) seen in the left temporal region (Figure 1) consistent with a diagnosis of a subpial hemorrhage (Option B).1 Several risk factors have been identified in full-term neonates that increase the risk of symptomatic intracranial hemorrhage; these include precipitous delivery, vaginal breech presentation, vacuum- or forceps-assisted vaginal delivery, prolonged duration of labor, primiparity, and high multiparity.
Neonatal subpial hemorrhage is characterized by extra-axial intracranial hemorrhage occurring between the cortical surface and the pia mater (Figure 2A).1–3 Bleeding in this confined space occurs due to the breakdown of perforating cortical veins, most commonly affecting the temporal lobe.1–3 Risk factors that are specific to a subpial hemorrhage include neonatal asphyxia, birth trauma, instrumental delivery, clotting disorders, variations in intracranial pressure, and venous sinus compression.1-4 Subpial hemorrhages are characteristically associated with focal cortical or subcortical infarction due to local venous congestion and obstruction to cortical venous outflow.1-4 Importantly, though head ultrasound is often the first-line modality for head imaging in the neonate, subpial hemorrhages are not always identified on head ultrasound. Diagnosis is possible by computed tomography, but MRI is preferred. The characteristic finding on a T2-weighted MRI resembles a “yin-yang” symbol, with a dark, focal subpial collection of blood into the cerebral sulci and a bright side denoting the underlying compressed cerebral cortex consistent with a venous infarct (Figure 3).1–3 Symptomatic neonates most commonly present with seizures, apnea, or focal neurologic deficits. The overall clinical picture and prognosis depend on the extent of the subpial bleed and underlying cortical injury.1
Figure 2. Layers of the meninges include the dura mater, arachnoid mater, and pia mater with locations of (A) subpial, (B) epidural, and (C) subdural hemorrhages.
Figure 3. T2-weighted MRI brain image of the neonate in the vignette with the characteristic “yin-yang” sign (red box) representing a focal subpial collection (yellow star) with underlying cortical infarct (red star). Image adapted from: Pollack R, Lamichhane A. Term infant with apnea. Neorviews. 2023;24(10):e670–6731
The collection of blood due to the rupture of vessels beneath the periosteum (subperiosteum) results in a cephalohematoma (Option A).5 Cephalohematomas are extracranial injuries restricted by periosteal attachments. These may present after birth as localized scalp swelling that does not cross suture lines, largest on postnatal day three (Figure 4).5 Unlike the neonate in the vignette, infants with a cephalohematoma are typically asymptomatic with an increased risk of indirect hyperbilirubinemia, and the hemorrhage generally resolves over weeks to months.5
Figure 4. Locations of common scalp and intracranial neonatal birth injuries. Image from: Whitesel E, Brodsky D. Fluctuant mass on an infant’s scalp. Neoreviews. 2018;19(8):e490–4926
The collection of blood due to the rupture of vessels beneath the periosteum (subperiosteum) results in a cephalohematoma (Option A).5 Cephalohematomas are extracranial injuries restricted by periosteal attachments. These may present after birth as localized scalp swelling that does not cross suture lines, largest on postnatal day three (Figure 4).5 Unlike the neonate in the vignette, infants with a cephalohematoma are typically asymptomatic with an increased risk of indirect hyperbilirubinemia, and the hemorrhage generally resolves over weeks to months.5
Rupture of large, bridging, emissary veins between the periosteum and gala aponeurotica is characteristic of a subgaleal hemorrhage (Option C) (Figure 4).5-8 Affected neonates typically present with diffuse scalp swelling that is fluctuant on palpation and obscures suture lines, features which were not present in the neonate in this vignette (Figure 5).4,8 Subgaleal hemorrhages can result in a collection of more than 40% of the neonate’s blood volume, leading to hemorrhagic shock, disseminated intravascular coagulation, and death.5,6
Figure 5. Computed tomography scan of a neonate with an extracranial subgaleal hemorrhage (yellow arrow). Image from: Singh A, Singh SN. Neonate with generalized scalp swelling and severe pallor. Neoreviews. 2016;17(8):e478–808
Accumulation of blood and serum in the subcutaneous tissue external to the periosteum and below the skin layer is consistent with caput succedaneum (Option D) (Figure 4). Unlike the infant in this vignette, infants with caput succedaneum present with scalp swelling that extends across the skull’s midline and crosses suture lines. This finding is often associated with ecchymosis or petechiae over the scalp but without significant blood loss.5 The swelling is often largest at the time of delivery and typically resolves within 48–72 hours.5,6
Very rarely, neonates may present with a linear skull fracture and underlying epidural hematoma, due to injury to the middle meningeal artery with a collection of blood between the skull and dura mater (Option E) (Figure 2B).5 Clinically, this complication is typically associated with seizures and hypotonia.5,9 On neuroimaging, epidural hematomas appear as a characteristic convex or “lens”-shaped hyperintensity, which was not seen in the MRI of the neonate in this vignette.9
Did you know?
The overall incidence of a subdural hemorrhage in an unassisted vaginal delivery is 2.9 per 10,000 deliveries. With vacuum-assisted and forceps-assisted deliveries, the incidence increases to 8 and 9.8 per 10,000 deliveries, respectively.10 Subdural hemorrhages are also highly associated with breech deliveries (Figure 2C).10
What are the most common neonatal complications associated with operative vaginal delivery?
For a comprehensive discussion of possible neonatal birth injuries after operative vaginal delivery, refer to Lueck T, Young B. Operative vaginal birth: neonatal implications for vacuum and forceps-assisted vaginal delivery. Neoreviews. 2023;24(1):e1–9 11
In a neonate with a suspected subgaleal hemorrhage, what are the recommended initial steps in management?
For a step-by-step approach to acute management of a subgaleal hemorrhage, refer to Mouhayar J, Charafeddine L. Head swelling and decreased activity in a 2-day-old term infant. Neoreviews. 2012;13(10):e615–6177
NeoQuest October Authors
Srirupa Hari Gopal, MBBS, FAAP, Baylor College of Medicine
Lila S. Nolan, MD, FAAP, Washington University School of Medicine
References:
- Pollack R, Lamichhane A. Term infant with apnea. Neoreviews. 2023;24(10):e670–673
- Zhuang X, Jin K, Li J, Yin Y, He S. Subpial hemorrhages in neonates: imaging features, clinical factors, and outcomes. Sci Rep. 2023;13(1):3408
- Ness TE, King BC, Kukreja M, Sundgren NC. Apnea spells in a term neonate. Pediatr Rev. 2021;42(11):616–618
- Cain DW, Dingman AL, Armstrong J, Stence NV, Jensen AM, Mirsky DM. Subpial hemorrhage of the neonate. Stroke. 2020;51(1):315–318
- Akangire G, Carter B. Birth injuries in neonates. Pediatr Rev. 2016;37(11):451–462
- Whitesel E, Brodsky D. Fluctuant mass on an infant's scalp. Neoreviews. 2018;19(8):e490–492
- Mouhayar J, Charafeddine L. Head swelling and decreased activity in a 2-day-old term infant. Neoreviews. 2012;13(10):e615–e617
- Singh A, Singh SN. Neonate with generalized scalp swelling and severe pallor. Neoreviews. 2016;17(8):e478–80
- Josephsen JB, Kemp J, Elbabaa SK, Al-Hosni M. Life-threatening neonatal epidural hematoma caused by precipitous vaginal delivery. Am J Case Rep. 2015;16:50–52
- Sims ME. 3 Vacuum-Assisted Deliveries, 3 Bad Outcomes. Neoreviews. 2018;19(9):e551–554
- Lueck T, Young B. Operative vaginal birth: neonatal implications for vacuum and forceps-assisted vaginal delivery. Neoreviews. 2023;24(1):e1–9