Subgaleal Hematoma From Hair-Combing

Subgaleal hematomas have been reported to occur in the pediatric population particularly in neonates with incidence ranging from 4 to 59 per 10,000 births¹. Subgaleal hematoma occurrence beyond the neonatal period is most often associated with head trauma involving tangential or radial forces applied to the scalp in which emissary veins are ruptured ^2,3. Children are predisposed to subgaleal bleeding due to a thinner scalp and more vascular subaponeurotic space than adults ⁴. A review of PubMed illustrated the rarity of subgaleal hematomas as only 12 cases were reported^{3,5,6,7,8,9,10,11,12}. Subgaleal hematoma was believed to result from hair-pull for the following reasons: the presence of thick hair that is difficult to pull, easily disrupted galeal-pericranial attachment, normal results of coagulopathy work-up, and no evidence of abuse or trauma⁵.

We report on a case of a 14-year-old male who presented to the emergency room with pain and swelling in the scalp of six days duration. Computed tomographic imaging revealed a 10.5 cm x 8.25 cm x 1.25 cm right frontotemporoparietal subgaleal hematoma. Following a thorough evaluation of the patient’s history—with no evidence of abuse or trauma—a detailed physical exam, and a normal hematology work-up, the swelling was determined to be secondary to hair-combing. The hematoma was drained three times: first, via an initial aspiration with drain and compression dressing application yielding 200cc of non-coagulated blood; second, via surgical evacuation; third, via repeat aspiration with compression dressing placement. Given multiple recurrences, a repeat CT head without contrast was obtained and a coronal incision was planned in the operating room for definitive treatment; however, when the patient presented for the operation, the hematoma had resolved. The patient has since failed to follow-up.

Subgaleal hematomas are rare and present a challenge to diagnose and treat. They are most often seen in the neonatal or pediatric populations secondary to vacuum-assisted births, or they have been associated with trauma, abuse, or coagulopathies^9,10,11. Subgaleal hematoma from hair-combing however, is particularly rare. Hematologic disorders need to be ruled-out and a thorough history, physical examination, and diagnostic imaging are paramount for proper diagnosis and treatment planning.

References:

1. Amar PA, et. al. (2003) Neonatal subgaleal hematoma causing brain compression: report of two cases and review of the literature. Neurosurgery. 25:1470–1474.

2. Slap, F.; et. al. Late onset subgaleal hemorrhage infection with Streptococcus pneumoniae? Eur J Pediatr. (2009) 168:647–650.

3. Vu, Tien T, et. al. Hematoma From Hair Braiding: Case Report and Literature Review. Pediatric Emerg Care. Dec 2004; 20(12): 821-823.

4. Adeloye A, Odeku EL. Subgaleal hematoma in head injuries. Int Surg. 1975;60(5):263-265.

5. Falvo, CE, et. al. Subgaleal Hematoma from Hair Combing. Pediatrics.1981: 68 (4), 583-584.

6. Hirosuke Fujisawa, H., et.al. A marked exophthalmos and corneal ulceration caused by delayed massive expansion of a subgaleal hematoma. Childs Nerv Syst. (2005) 21: 489–492.

7. Yip, CC., et.al. Proptosis After Hair Pulling. Ophthal Plast Reconstr Surg, vol. 19, No. 2, 2003.

8. Madhu SV, Agarwal S. Subgaleal hematoma following hair pulling. J Assoc Physicians India.1990 Dec; 38(12):955.

9. Kim D, Taragin B. Subgaleal hematoma presenting as a manifestation of Factor XIII deficiency. Pediatr Radiol.2009 Jun;39(6):622-4.

10. Onyeama CO, et. al. Subgaleal hematoma secondary to hair braiding in a 31-month-old child. Pediatr Emerg Care.2009 Jan;25(1):40-1.

11. Seifert D, Püschel K. Subgaleal hematoma in child abuse. Forensic Sci Int.2006 Mar 10;157(2-3):131-3.

12. Hamlin, H. and Scott, M. Subgaleal hematoma caused by hair pull. JAMA. 1968 Jul 29; 205(5):314.