Subgaleal hematoma with retrobulbar extension

Case contributed by Ammar Ashraf
Diagnosis certain

Presentation

Non-traumatic headache and scalp swelling for three days. History of similar episode 8 months ago. Patient developed bilateral proptosis 2 days later.

Patient Data

Age: 4 years
Gender: Male

Large heterogeneous mildly hyperdense right frontoparieto-occipital scalp swelling likely representing a subgaleal hematoma. No underlying acute skull bone fracture is seen. Focal encephalomalacic changes in the left parietal region, with mild focal thinning of the overlying parietal bone, likely related to the past history of trauma. No acute intracranial or intraorbital hemorrhage is seen.

Interval increase in the subgaleal hematoma along with interval development of mildly hyperdense bilateral extraconal/retrobulbar hemorrhages with consequent proptosis, The retrobulbar hemorrhages are likely the extensions of the subgaleal hematoma.

Large subgaleal hematoma and bilateral retrobulbar hemorrhages without any history of trauma. Based on the history and imaging findings, possibility of bleeding/clotting disorder, non-accidental injury, vascular malformation or vasculitis was raised and further workup was advised. 

 

Case Discussion

Laboratory investigations:

  • Hemoglobin: 71 gm/L (Reference value=110-145 gm/L).

  • Platelets: 126 x 109/L (Reference=150-450 x 109/L).

  • Prothrombin time (PT): 10.6 seconds (Reference value=9.38-12.34 seconds).

  • INR: 1.2 (Reference value=0.80-1.20).

  • D-Dimer: 3.80 mg/L (Reference value=0.00-0.50 mg/L).

  • Von Willebrand factor Antigen (VW Factor): >200 % (Reference value=50-160 %).

  • Factor XIII: 0.18  (Reference value=0.7-1.40 unit/ml).

  • Blood coagulation: Platelet aggregation study result is abnormal for arachidonic acid (AA), ADP and epinephrine. Normal closure time with collagen/epi cartridge.

  • Peripheral blood smear: Anemia with anisocytosis, mild polychromasia, occasional hyper segmented neutrophils and mild thrombocytopenia. 

  • Autosomal recessive platelet glycoprotein IV deficiency (homozygous likely pathogenic variant identified in CD 36 gene on genetic analysis).

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