⚠️ 122.2 Neonatal Traumatic Head Injuries
Nelson's Textbook of Pediatrics | Subdural Hemorrhage · Tentorial/Falcine Tears · Subarachnoid Hemorrhage · Epidural Hematoma · Child Abuse Consideration
⚠️ Neonatal Traumatic Head Injuries (122.2) 📊 Epidemiology Affects ~3% of pregnancies Represents ~2% of neonatal deaths Risk factors: macrosomia, prolonged labor, breech, precipitous delivery, instrument-assisted (forceps/vacuum) 🩸 Subdural Hemorrhage Most common intracranial injury at birth Often associated with tentorial or falcine tears Massive hemorrhage → rapid deterioration, death Most are small and asymptomatic (incidental on imaging) Posterior fossa most common site Symptomatic: macrocephaly, bulging fontanel, seizures Treatment: neurosurgical evacuation if symptomatic 🧠 Subarachnoid Hemorrhage Usually clinically silent Source: bridging veins or leptomeningeal anastomoses May cause brief, benign seizures on day 2 of life Rarely catastrophic with death No neurologic sequelae in most cases ⚠️ Epidural Hematoma & Child Abuse Epidural hematoma rare in neonates (usually from skull fracture) Subdural effusion after neonatal period → suspect child abuse Most asymptomatic subdural hemorrhages resolve by 4 weeks 🔬 Diagnosis & Treatment CT scan or MRI for diagnosis Asymptomatic: observation, no intervention Symptomatic subdural: needle evacuation via fontanel or burr hole Arteriovenous malformation → consider if recurrent hemorrhage 💡 Key Pearl Most neonatal intracranial hemorrhages are benign and self-resolving
🔑 Key: Subdural hemorrhage most common; most asymptomatic. Tentorial tear can be catastrophic. Subarachnoid hemorrhage → day 2 benign seizures. Suspect child abuse for subdural beyond neonatal period.
📌 Section 122.2 – Neonatal Traumatic Head Injuries (Nelson's 22e) Core Summary

1. Epidemiology & Risk Factors
• Affects ~3% of pregnancies; represents ~2% of neonatal deaths.
• Risk factors: macrosomia (large head relative to pelvic outlet), prolonged labor, breech presentation, precipitous delivery, mechanical assistance (forceps, vacuum).
• Occurs during normal birth but incidence rises with difficult delivery.

2. Subdural Hemorrhage
• Most common intracranial injury at birth; more common in term than preterm infants.
• Often associated with tears in the tentorium cerebelli or falx cerebri.
• Massive hemorrhage from tentorial/falcine tear → rapid deterioration, death soon after birth.
• Most subdural hemorrhages are small, asymptomatic, and resolve without intervention. Especially common in posterior fossa.
• Asymptomatic subdural may be noted incidentally on imaging within 48h of vaginal or cesarean delivery.
• Delayed presentation: chronic subdural fluid expansion → macrocephaly, frontal bossing, bulging fontanel, anemia, seizures.
• Diagnosis: CT scan or MRI.
• Treatment: symptomatic cases → neurosurgical evacuation via needle through lateral anterior fontanel, or burr hole/craniotomy for severe cases.
• Most asymptomatic subdural hemorrhages resolve by 4 weeks of age.
• Important: Subdural effusion after the immediate neonatal period should raise suspicion for child abuse.

3. Subarachnoid Hemorrhage
• Often clinically silent in neonates.
• Source: anastomoses between penetrating leptomeningeal arteries or bridging veins.
• May be detected incidentally by elevated RBCs on lumbar puncture.
• Some infants experience brief, benign seizures on day 2 of life.
• Rarely, catastrophic hemorrhage with death.
• Usually no neurologic abnormalities on follow-up.
• Significant neurologic findings should prompt evaluation for arteriovenous malformation (CT or MRI).

4. Epidural Hematoma
• Rare in neonates.
• Usually associated with skull fracture.
• Most resolve without intervention.

5. Child Abuse Consideration
• Subdural effusion or hemorrhage presenting after the immediate neonatal period (beyond first few weeks) should raise suspicion for non-accidental trauma (shaken baby syndrome).
• Always maintain high index of suspicion for inflicted head injury.

💡 Pearls: Most neonatal traumatic head injuries are benign and self-limited. Subdural hemorrhage is most common but usually asymptomatic. Subarachnoid hemorrhage can cause benign day 2 seizures. Any subdural beyond the neonatal period → consider child abuse.