Surgical drain induced subgaleal hematomas and skin necrosis in pediatrics: a case report.

INTRODUCTION: Subgaleal drainage is often being used in craniotomy procedures. It's not only offers advantages but also carries a risk of life-threatening complications. Here, we present a rare case of subgaleal hematoma and skin necrosis caused by placement of subgaleal drainage in a pediatric patient after a craniotomy procedure. CASE REPORT: We reported a 6-months-old child who came to our institution complaining of uncontrolled eye movements which occurred 4 months earlier. From the CT scan and MRI, it was found that the patient had a mass in his suprasellar region, which suggested a suprasellar tumor. She underwent a mass resection procedure, but unfortunately, 3 days after the surgical procedure, the wound appeared necrotic, with a blackish color around the drain. The necrotic wound was suspected due to vacuum subgaleal drain placement. The wound was cleaned and the suture removed, but the necrotic area was still there. Four days after the surgery, the patient clinical condition got worse. After 17 days of treatment with no significant improvement, unfortunately, the patient died. DISCUSSION: The mechanism of subgaleal hematoma and skin necrosis induced by the Redon drain possibly related to mechanical compression by the drain, which damage perforating vessels and subsequently disrupt skin vascularization, combined with vascular stasis as given by negative pressure of the drain. This induced skin ischemia lesion which later contributes the necrotic formation. CONCLUSION: The subgaleal hematoma and skin necrosis as a complication of subgaleal redon drain in pediatric are rare phenomenon and likely under reported. The possible underlying mechanism was that drain's negative pressure disrupt subgaleal tissue and induce necrotic formation. Even the complication is rare compared to older children, yet it has been linked to an increased risk for infection, morbidity, and mortality.

Algorithm of Traumatic Brain Injury in Pregnancy (Perspective on Neurosurgery).

BACKGROUND: The maternal deaths due to obstetrical cases declined, but the maternal deaths that caused by nonobstetrical cases still increase. The study reported that traumatic cases in pregnancy are the highest causes of mortality in pregnancy (nonobstetrical cases) in the United States. Another study reported that 1 in 12 pregnant women that experienced traumatic accident and as many as 9.1% of the trauma cases were caused by traumatic brain injury (TBI). The female sex hormone has an important role that regulates the hemodynamic condition. Anatomical and physiological changes during pregnancy make the examination, diagnosis, and treatment of TBI different from non-pregnant cases. Therefore, it is very important to lead the algorithm for each institution based on their own resources. CASE SERIES: A 37-year-old woman with a history of loss of consciousness after traffic accident. She rode a motorbike then hit the car. She was referred at 18 weeks' gestation. Glasgow Coma Scale (GCS) E1V1M4, isochoric of the pupil, reactive to the light reflex, and right-sided hemiparesis. The non-contrast head computed tomography (CT) scan revealed subdural hematoma (SDH) in the left frontal-temporal-parietal region, SDH of the tentorial region, burst lobe intracerebral hemorrhage, and cerebral edema. There was not a fetal distress condition. The next case, a 31 years old woman, in 26 weeks gestation, had a history of unconscious after motorcycle accident then she fell from the height down to the field about 3 m. GCS E1V1M3, isochoric of the pupil, but the pupil reflex decreased. Noncontrast CT scan revealed multiple contusion, subarachnoid hemorrhage, and cerebral edema. She had a good fetal condition. DISCUSSION: We proposed the algorithm of TBI in pregnancy that we already used in our hospital. The main principle of the initial management must be resuscitating the mother and that also the maternal resuscitation. The primary and secondary survey is always prominent of the initial treatment. CONCLUSION: The clinical decision depends on the condition of the fetal, the surgical lesion of the intracranial, and also the resources of the neonatal intensive care unit in our hospital.