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Fluctuating scalp swelling - a case of massive subgaleal bleed following minor head injury

Subgaleal haematoma is rare in paediatric age group except in the new-born observed after instrumental delivery. Literature review suggests its association with underlying coagulation disorders, vascular malformations or head trauma. We present case report of an 8 year old girl, who presented with a scalp swelling. This swelling was initially localised to right parietal region progressing to involve whole of scalp over next 48 hours. Mother was also concerned about her pale appearance. She had a minor head injury at school two weeks back, when during play with friends, she accidently fell and hit the back of her head against a brick wall. There was no laceration, bruising, scalp swelling or amnesia or loss of consciousness. There was no history of easy bruising or bleeding or history of bleeding disorder in the family. On examination, she looked pale with a massive boggy non tender and fluctuant scalp swelling extending from above supraorbital ridges to the occiput and laterally, a few centimetres above pinna bilaterally. Skull X-ray in accidents and emergency revealed soft tissue swelling with no fracture. There was no focal neurology though she started to have frequent vacant episodes with extreme pallor but responsive to tactile stimulation. Urgent CT scan with contrast was organised which showed large diffuse subcutaneous swelling of scalp, right occipital, bilateral frontal and parietal convexities containing multiple hyper dense areas suggesting focal areas of haemorrhage. Her Haemoglobin at admission was 12 g dropped to 10 g on repeat testing 4 days later which was associated with pallor, periorbital puffiness and headache. She was investigated for bleeding disorders including coagulation defects and platelet function anomalies after discussion with haematologist which were all normal. She was managed conservatively and later discharged home.