Fatal newborn head enlargement: high resolution magnetic resonance imaging at 4.7 T

A male term infant (41⁺² weeks gestational age), born in excellent condition after ventouse delivery, presented at 2 hours with pallor and metabolic acidosis (capillary blood sample pH 6.45, base excess −34). He rapidly became encephalopathic, developed disseminated intravascular coagulopathy, multiorgan failure, and an increasing head circumference (41 cm at presentation compared with 35 cm at birth). Despite aggressive blood product replacement and an attempt at draining the scalp haematoma, his condition deteriorated. Neurosurgical intervention was considered but felt inappropriate.

Magnetic resonance imaging was performed at 4.7 T on day 3 after birth using an optimised fast spin echo protocol (TE  =  88 milliseconds, TR  =  3.5 seconds, eight echoes).1 The resulting T₂ weighted images confirmed the clinical diagnosis of subgaleal haemorrhage. In addition to uncal and transtentorial herniation, haemorrhagic infarction involving deep grey matter, cerebellum, and spinal cord were observed (fig 1). A clear loss of grey/white matter differentiation suggested widespread cellular injury (fig 2). The patient died on day 5. A post mortem examination with neuropathology confirmed the location of the brain and spinal cord lesions and their hypoxic/ischaemic aetiology. There was also ischaemic injury to internal somatic organs. Clinical investigation of any underlying abnormality such as haemophilia or platelet isoimmunisation was not possible, because of repeated transfusions; nor could this be tested for in autopsy material.

Figure 1 Sagittal magnetic resonance scan. The large arrow indicates subgaleal haemorrhage; the small arrows indicate signal intensity changes indicative of haemorrhagic infarction.

Figure 2 Coronal magnetic resonance scan. The large arrow indicates subgaleal haemorrhage. A clear loss of grey/white matter differentiation can be observed, suggesting widespread cellular injury.

Subgaleal haemorrhage is a potentially lethal condition in newborns, with a prevalence of about 0.4–1.6 per 1000 births in moderate to severe cases.2,3,4 It is more common with ventouse assisted deliveries, for which the reported risk is about 60 times higher than in other modes of delivery.4,5 Subgaleal haemorrhage is caused by rupture of emissary veins that connect the dural sinuses and the scalp veins. As there is no space restriction between the epicranial aponeurosis and periosteum, up to 260 ml blood can be lost into this space with only a moderate increase in head circumference.2 These first images of the newborn brain at 4.7 T show, with remarkable detail, the extent of the subgaleal haemorrhage and intracranial haemorrhagic infarction consequent to severe hypovolaemic shock. With the increasing use of vacuum extraction for assisted deliveries, an awareness of this condition among paediatricians is imperative.