Reminder of important clinical lesson

Spontaneous perinatal epidural haemorrhage in a newborn
Elke Kroon, Levinus A Bok, Feico Halbertsma
Pediatrics Department, Maxima Medisch Centrum Veldhoven, Veldhoven, Netherlands
Correspondence to Dr Feico Halbertsma, f.halbertsma@mmc.nl

Summary
A full-term neonate, born by caesarean section, presents with focal seizures. EEG and cranial ultrasound are normal. MRI of the cerebrum
shows an epidural haematoma. Perinatal intracranial haemorrhage in the full-term newborn is an important cause of morbidity and mortality.
Most perinatal intracranial haemorrhages are located either subdural or intracerebral, rarely epidural. Epidural haemorrhage is usually a
complication of assisted delivery, however it may also occur without forcipal or vacuum extraction, as demonstrated in this case. An epidural
haemorrhage should be suspected on clinical findings, even in the absence of an assisted delivery. As cranial ultrasound sonography often
misses epidural haemorrhage due to parietal location of the haemorrhage, the diagnosis needs either cerebral CT or MRI.

BACKGROUND
Intracranial haemorrhage in the full-term neonate is an
important cause of morbidity and mortality. Although the
prevalence is low, it should be included in the differential
diagnosis of perinatal neurologic morbidity, because early
diagnosis can be lifesaving. Symptoms at presentation,
such as seizures, anaemia, apnoea and bradycardia, are
non-specific.1
Most perinatal intracranial haemorrhages are either subdural or intracerebral. A spontaneous perinatal epidural
haemorrhage as reported in this case is seldom seen, and is
especially rare in the absence of vacuum of forceps assisted
delivery. Nevertheless, it should be included in the differential diagnosis of perinatal neurologic symptoms, as early recognition favours better outcome. Diagnostic investigation
consisting of only ultrasound may easily miss epidural haematoma, due to its peripheral location, and should consist of
also include MRI or CT to detect parietal abnormalities.

CASE PRESENTATION
A male full-term neonate, born after an uneventful pregnancy, was seen at the maternity ward 30 h postpartum with
focal seizures of his left hand and forearm. He was born by
caesarean section, after a prolonged second stage delivery of
19 h. During the caesarean section, several manipulations
were necessary for the delivery of the head. The Apgar score
was 4 at 1 min and 9 at 5 min. At physical examination no
congenital abnormalities or malformations wee seen.

INVESTIGATIONS
Physical examination 30 h after birth showed twitches in
the patients left hand and forearm. Neurologic and general
paediatric physical examination was normal. The cerebral
function monitoring (CFM) suggested a centro-parietal epileptic focus however the EEG was normal. Cranial sonography showed no abnormalities. Culture of cerebrospinal
fluid was sterile, but the cerebrospinal fluid contained some
erythrocytes. MRI of the cerebrum (figure 1) showed an
epidural haematoma and a small arachnoidal haematoma
on the right parietal side. Diffusion-weighted imaging
BMJ Case Reports 2012; doi:10.1136/bcr.09.2011.4735

showed cortical highlighting on both parietal-occipital
sides. Screening for haematological and metabolic disorders
was negative. Phenobarbital stopped the epileptic activity.

OUTCOME AND FOLLOW-UP
At follow-up at 6 months of age the child had a normal
neurologic development and antiepileptic medication was
discontinued. Head circumference was frequently measured, and remained within normal range.

DISCUSSION
Neonatal epidural haemorrhage is very uncommon, but
when it occurs it is often a complication of vacuum and
forceps assisted delivery. Perinatal epidural haemorrhage
in the absence of both vacuum/forceps assisted delivery
and underlying disorders is even more rare. Previous case
reports describe perinatal epidural haemorrhage in association with co-morbidities, such as Prader–Willi syndrome,
Chiari malformation, haemophilia or other haemostasis
disorders. Contrary to older children and adults, vascular malformations are not reported as a cause of epidural
haemorrhages.1
Although cranial sonography is the initial diagnostic
modality used in children suspected of intracranial haemorrhage, it is not an appropriate tool to visualise epidural
haematoma, because they are typically located in the
parietal area. Therefore CT scan or MRI of the cerebrum
are more appropriate; where CT has the advantage of not
needing anaesthesia/sedation contrary to MRI, the latter
provides more detailed information about the brain tissue
and structural changes.1
Epileptic activity can be diagnosed and monitored by
both CFM and EEG although CFM may miss focal epileptic activity due to limited number of leads. Surprisingly
in this case, EEG showed no abnormalities whereas CFM
was positive for epileptic activity, demonstrating that occasionally also malpositioning of EEG probes can miss focal
epileptic activity.
The anatomic site of an epidural haematoma – blood
located between the periostal membrane and the underlying
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Figure 1

Inversion recovery prepared turbo spin echo sequence MRI: epidural haematoma on the right parietal side.

outer dural fibrous stratum or between any skull bone and
its periost – explains why this can arise during birth: to
cause an epidural hematoma there must be a cleavage
between bone and dura mater, which is always traumatic.
The bone can be dislocated due to an increased moulding of the vault’s bones during labour. Dura-bone cleavage
occurs when the elasticity limits of the fetal dura mater is
exceeded, usually during forceps or vacuum extraction, or
incidentally during unassisted birth as in this case.2 3
As in neonates the meningeal arteries are not embedded
in the skull, this allows for larger moulding without vascular rupture. This probably explains that when epidural
haemorrhage occurs it is not confined to arterial rupture (as
in children and adults), but can also arise from capillary or
(sino)venous rupture when the fibro-vascular connection
between the dura and bone becomes detached.
The presentation of neonatal epidural haemorrhage
can be heterogeneous. It can present with a variety of
symptoms or can be asymptomatic. The most common
symptoms are pallor, a decrease of the haematocrit and
an increasing head circumference. Neurological symptoms
can be decreased consciousness, central apnea, hypotonia
and/or seizures. In most cases symptoms develop within
the first 24 h after birth.2 4 Because the skull plates are not
fused, classic raised intracranial pressure features due to
brain shift can present late. Monitoring fontanel turgor,

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head circumference, feeding behaviour and seizure frequency is vital.
When the haemorrhage results in an increased intracranial pressure, compression of brain tissue and eventually
a shift of the brain, surgical evacuation is necessary. Some
epidural haematomas communicate with cephalic haematomas and may respond to aspiration.5 Small epidural
haemorrhage usually resolve in time. Prognosis and outcome of perinatal epidural haemorrhage is generally good,
when diagnosed in an early stage.
In conclusion, epidural haemorrhage is a rare complication of birth and can follow in a delivery without vacuum
or forceps assistance. Diagnosis should be suspected following clinical symptoms. As cranial sonography is not an
appropriate diagnostic modality due to parietal location of
the haemorrhage, either CT of MRI is warranted.

Learning points
Epidural haemorrhage, although very rare, should be a
differential diagnosis in neonatal convulsions.
▶ Epidural haemorrhage can also be a complication of
non-vacuum or non-forceps assisted birth.
▶ Cranial sonography is insufficient as diagnostic tool for
detecting epidural haemorrhage.
▶

BMJ Case Reports 2012; doi:10.1136/bcr.09.2011.4735

Acknowledgements The authors thank Dr Walther Tjon a Ten for critically
reviewing the manuscript.
Competing interests None.
Patient consent Obtained.

REFERENCES
1. Heyman R, Heckly A, Magagi J, et al. Intracranial epidural hematoma in
newborn infants: clinical study of 15 cases. Neurosurgery 2005;57:924–9;
discussion 924–9.

2. Gama CH, Fenichel GM. Epidural hematoma of the newborn due to birth
trauma. Pediatr Neurol 1985;1:52–3.
3. Hamlat A, Heckly A, Adn M, et al. Pathophysiology of intracranial epidural
haematoma following birth. Med Hypotheses 2006;66:371–4.
4. Ou-Yang MC, Huang CB, Huang HC, et al. Clinical manifestations of
symptomatic intracranial hemorrhage in term neonates: 18 years of
experience in a medical center. Pediatr Neonatol 2010;51:208–13.
5. Yamamoto T, Enomoto T, Nose T. Epidural hematoma associated with
cephalohematoma in a neonate–case report. Neurol Med Chir (Tokyo)
1995;35:749–52.

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Kroon E, Bok LA, Halbertsma F. Spontaneous perinatal epidural haemorrhage in a newborn. BMJ Case Reports 2012;10.1136/bcr.09.2011.4735, Published XXX
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