Management and outcome of spontaneous subaponeurotic fluid collections in infants: the Hospital for Sick Children experience and review of the literature

Abstract

<jats:sec> <jats:title>OBJECTIVE</jats:title> <jats:p>Spontaneous subaponeurotic fluid collection (SSFC) is an uncommon and newly described entity of unknown etiology, observed in infants less than 1 year of age. The authors report on series of infants who presented to the Hospital for Sick Children (HSC) with SSFC, focusing on the natural history of this condition.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>Data from the Hospital for Sick Children were retrospectively reviewed for the period between January 2004 and June 2015. Patient age and sex, birth history, medical history, laboratory findings, and symptoms were reviewed. SSFC location, imaging characteristics, management, and outcome were also analyzed. A MEDLINE and Embase literature search was performed on the condition, yielding previously reported cases of SSFC in the English language.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>Nine cases involving patients who presented with SSFC during the study period were identified. The patients were 4 male and 5 female infants (age range 5 weeks to 11 months). All cases of SSFC developed spontaneously over a period of days, and the infants had no history of injuries, trauma, or hair manipulation in the immediate period preceding the development of the subgaleal collections. Six patients underwent remote forceps- or vacuum-assisted instrumented births, although none of the patients developed scalp collections or skin discoloration immediately after birth. All of the cases were managed conservatively on an outpatient (6 cases) or inpatient (3 cases) basis. In 1 case, the size of the fluid collection fluctuated over 4 months, but in all of the cases, the collections resolved spontaneously without structural or infectious complications.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>This is the largest series describing SSFC to date and summarizes 9 cases managed at a large academic neurosurgical center. Although the specific pathophysiology of SSFC remains unknown, in some cases the condition may be associated with a remote history of instrumented delivery. SSFC occurs spontaneously without immediate preceding trauma, and an extensive hematology or child abuse workup is not necessary. A conservative approach with outpatient follow-up is advocated.</jats:p></jats:sec>

Solving the Mystery of a 1-Month-Old Infant With Scalp Swelling: Search the Literature First

“…2,3 Adverse outcomes have not been reported. 3,4 As in our case, many providers have not encountered a case of SFC previously. Worthen et al 1 surveyed parents of 69 infants who posted blogs on a patientsupport Web site describing clinical features of SFC.…”

“…3 Cases involving infants delivered by emergency cesarean delivery and prolonged labor have been reported. 4,6 Petraglia et al 6 reported 3 infants who all had scalp electrodes placed during labor. They postulated that scalp trauma from the electrode placement caused a cerebrospinal fluid (CSF) leak.…”

“…Needle aspiration of fluid has not been associated with quicker resolution, and frequently the fluid reaccumulates rapidly. 4 Time to resolution varies ranging from 1 to 24 weeks. 2,3 Adverse outcomes have not been reported.…”

“…Although most infants are evaluated in an outpatient setting, knowledge of SFC is important for hospitalists. In the case series by Wang et al, 4 3 of the 4 infants that presented to the ED were admitted. In any setting, physical child abuse must be considered for an infant presenting with scalp swelling and no history of trauma, because subaponeurotic or subgaleal hemorrhage has been described with inflicted head trauma.…”

Delayed subaponeurotic fluid collection of infancy

“…Authors have been unanimous in recommending against child protection involvement unless otherwise indicated. [1][2][3][4][5][6][7][8] Ultrasound demonstrates an anechoic collection within the subgaleal space. Computed tomography and magnetic resonance imaging do not demonstrate a skull fracture or intracranial pathology.…”