Subgaleal Hemorrhage: Symptoms, Types, Causes and Treatment

Subgaleal hemorrhage (SGH) is a rare but potentially life-threatening condition, most commonly encountered in newborns, but also seen in older children and even adults in exceptional cases. Its significance lies not just in its rarity but in its capacity for rapid deterioration, making swift recognition and intervention essential for survival. This article unpacks the symptoms, types, causes, and effective treatment strategies for subgaleal hemorrhage, drawing on contemporary scientific literature and clinical cases.

Symptoms of Subgaleal Hemorrhage

Early identification of subgaleal hemorrhage is vital for preventing severe complications. Symptoms can range from subtle changes to acute, life-threatening presentations. Understanding these signs aids caregivers and clinicians in making prompt, life-saving decisions.

Symptom	Onset	Associated Findings	Source(s)
Scalp swelling	Acute	Ballotable, fluctuating mass	1 3 7 8
Pallor	Rapid	Anemia, hypovolemia	1 2 7
Hypotension	Acute	Shock, tachycardia	1 2 7 8
Falling hematocrit	Rapid	Blood loss, anemia	1 2 9
Jaundice	Subacute	Hyperbilirubinemia	1 2 3
Tachycardia	Acute	Shock	1 2 7 8
Neurological changes	Variable	Lethargy, poor feeding	2 7 8

Table 1: Key Symptoms

Scalp Swelling

The most prominent and earliest sign of subgaleal hemorrhage is a diffuse, fluctuant swelling of the scalp. Unlike cephalohematoma or caput succedaneum, this swelling can cross suture lines and is often soft or "ballotable" to the touch. The swelling may expand rapidly, reflecting ongoing blood loss beneath the scalp aponeurosis 1 3 7 8.

Systemic Signs: Pallor and Hypotension

As blood accumulates in the potential subgaleal space, neonates (and occasionally older children) may develop pallor due to acute anemia. Significant blood loss may precipitate hypovolemic shock, characterized by hypotension, tachycardia, and poor perfusion 1 2 7 8. In severe cases, infants can lose up to 20-40% of their total blood volume into this compartment.

Laboratory Findings: Falling Hematocrit & Jaundice

A rapid drop in hematocrit is a hallmark laboratory sign indicating significant blood loss 1 2 9. As red blood cells are broken down, hyperbilirubinemia and subsequent jaundice can develop, especially if the hemorrhage evolves slowly 1 2 3.

Neurological and General Symptoms

Infants may display lethargy, poor feeding, irritability, or altered consciousness if cerebral perfusion drops or if there is associated brain injury. These neurological changes are warning signs of progression and possible complications 2 7 8.

Types of Subgaleal Hemorrhage

Subgaleal hemorrhage is not a one-size-fits-all condition. It can be classified based on patient age, underlying causes, and clinical context. Recognizing these distinctions is important for prognosis and management.

Type	Patient Group	Trigger/Event	Source(s)
Neonatal	Newborns	Birth trauma (instrumental)	1 2 3 4 7 8
Traumatic	Children/adults	Falls, accidents	6 9
Spontaneous	Any age	Vascular anomaly, coagulopathy	5 6 9
Procedure-related	Adults	Neurosurgical drains	10 11

Table 2: Subgaleal Hemorrhage Types

Neonatal Subgaleal Hemorrhage

This is the most recognized form and is predominantly linked to birth trauma, particularly following vacuum-assisted or forceps deliveries 1 2 3 4 7 8. The rupture of emissary veins during delivery leads to blood pooling between the scalp aponeurosis and the skull. Neonatal SGH is notable for its rapid progression and risk of fatality if not quickly addressed.

Traumatic Subgaleal Hemorrhage

Older children and adults can develop SGH after direct head trauma, such as falls or accidents. In these cases, the hemorrhage may be less dramatic but can still lead to significant complications if misdiagnosed or untreated 6 9. In children, hair-pulling or tight hairstyles have been reported as rare causes 6.

Spontaneous Subgaleal Hemorrhage

In rare instances, SGH can occur without an obvious traumatic event, typically due to underlying vascular malformations or coagulopathies 5 6 9. These cases are often more insidious in onset and may be associated with other bleeding tendencies.

Procedure-Related Subgaleal Hemorrhage

In adults, some neurosurgical procedures (such as subgaleal drainage for hematomas) may involve deliberate or accidental creation of a subgaleal space, with hemorrhage as a potential complication 10 11. These are managed in a hospital setting and are distinct from spontaneous or trauma-related cases.

Causes of Subgaleal Hemorrhage

Understanding the underlying causes of SGH is crucial for prevention and targeted management, especially in high-risk populations.

Cause	Mechanism	Risk Factors	Source(s)
Birth trauma	Emissary vein rupture	Vacuum/forceps, prolonged labor	1 2 3 4 7 8
Direct trauma	Blunt force to scalp	Falls, accidents, hair-pulling	6 9
Coagulopathy	Impaired clotting	Hemophilia, bleeding disorders	4 5 6 9
Vascular anomaly	Spontaneous rupture	Periosteal varix, malformations	5
Surgical/procedural	Iatrogenic injury	Neurosurgical drains	10 11

Table 3: Causes of Subgaleal Hemorrhage

Birth Trauma: The Leading Cause in Neonates

The vast majority of neonatal SGH cases result from birth trauma. Vacuum extraction and forceps deliveries are particularly incriminated, with vacuum extraction carrying the highest risk 1 2 3 4 7 8. Prolonged second stage of labor and fetal distress further increase the likelihood of injury to the scalp’s vascular structures. The negative pressure of vacuum devices, especially if misapplied or used for extended periods, can rupture fragile emissary veins.

Direct Head Trauma

In older children and adults, subgaleal hemorrhage typically follows blunt trauma to the scalp—falls, motor vehicle accidents, or even vigorous hair manipulation (braiding, pulling, tight ponytails) 6 9. These can cause shearing or tearing of the scalp’s vascular plexus.

Coagulopathy and Vascular Malformations

Bleeding disorders such as hemophilia or acquired coagulopathies may predispose patients to spontaneous SGH even with minor trauma or no apparent trigger 4 5 6 9. Rarely, vascular anomalies such as periosteal varices can be the source of spontaneous hemorrhage 5.

Iatrogenic Causes

Medical procedures involving the scalp, such as drainage of subdural hematomas or placement of shunts, can occasionally lead to SGH as a complication 10 11. These are typically recognized and managed in specialized settings.

Treatment of Subgaleal Hemorrhage

Timely and aggressive management is critical to improve outcomes in subgaleal hemorrhage. Treatment strategies are tailored to the severity of bleeding, patient age, underlying cause, and the presence of complications.

Treatment	Approach	Indications	Source(s)
Supportive care	Monitoring, fluids	Mild cases, stable patients	1 3 6 9
Blood transfusion	Restore volume	Anemia, shock, large SGH	1 2 7 8
Surgical drainage	Evacuation	Expanding or nonresolving SGH	6 9
Treat underlying cause	Coagulopathy management	Hemophilia, bleeding disorders	4 5 6 9
Intensive monitoring	Vital signs, labs	All neonates at risk	1 2 7 8

Table 4: Treatment Strategies

Supportive Care and Monitoring

Most cases, especially mild or slowly resolving SGH, can be managed with close observation. This includes frequent monitoring of head circumference, vital signs, neurological status, and serial laboratory studies to track hematocrit and bilirubin levels 1 3 6 9. Early detection of worsening bleeding is critical.

Blood Transfusion and Volume Resuscitation

Severe hemorrhages require prompt restoration of blood volume with transfusions and intravenous fluids. This is often life-saving in neonates who can lose a significant portion of their circulatory volume into the subgaleal space 1 2 7 8. Correction of anemia and stabilization of hemodynamics are top priorities.

Surgical Intervention

In select cases—typically when the hematoma is rapidly enlarging, causing neurological compromise, or not resolving—surgical aspiration or drainage may be necessary 6 9. This is more common in older children or when the hematoma extends into adjacent compartments (e.g., orbit).

Treating Underlying Disorders

Where coagulopathy or a vascular anomaly is identified, specific medical or surgical management is needed. For instance, hemophilia may require factor replacement, and vascular malformations may need intervention to prevent recurrence 4 5 6 9.

Intensive Monitoring After Instrumental Delivery

For neonates delivered via vacuum or forceps, protocols recommend systematic monitoring for at least 24 hours post-delivery, watching for scalp swelling, vital sign changes, and laboratory abnormalities 1 2 7 8. Early intervention in this window is associated with improved outcomes and reduced mortality.

Outcomes and Prognosis

Prompt recognition and aggressive management have drastically reduced the risk of long-term neurological deficits in survivors. Most infants who survive the acute episode of SGH show no lasting developmental delays or neurological impairments 2. However, delayed diagnosis or inadequate resuscitation can lead to fatal outcomes.

Conclusion

Subgaleal hemorrhage, while rare, demands vigilance and swift action from clinicians and caregivers alike. Awareness of its symptoms, risk factors, and management principles can make the difference between life and death, especially in newborns.

Key points covered:

• Subgaleal hemorrhage is most common in newborns, often following vacuum or forceps-assisted deliveries 1 2 3 4 7 8.
• Early symptoms include scalp swelling, pallor, hypotension, and falling hematocrit; delayed recognition can result in shock or death 1 2 7 8.
• Types include neonatal (birth trauma), traumatic (accidents, hair manipulation), spontaneous (coagulopathy, vascular anomaly), and iatrogenic (procedures) 5 6 9 10 11.
• Main causes are birth trauma, direct head trauma, coagulopathy, and rare vascular anomalies 1 2 3 4 5 6 7 8 9.
• Treatment focuses on supportive care, transfusion, surgical drainage when needed, and management of underlying causes, with strong emphasis on monitoring at-risk infants 1 2 3 6 7 8 9.

Early diagnosis, meticulous monitoring, and targeted intervention remain the pillars of effective care in subgaleal hemorrhage.