Grand Rounds Hair Pulling & Vision Loss

1. Grand RoundsHair Pulling & Vision Loss Sidharth Puri MD, PGY4 August 10, 2018

2. Patient Presentation CC Headache, decreased vision and left eye pain HPI • 13 yo African American male presenting with headache 5 days after hair was pulled at school • Initial CT showed subgaleal hematoma, no orbital or ocular involvement. • Returned to ER 2 days later with worsening headache, new onset left eye pain, and decreasing vision

4. History (Hx) Past Ocular Hx-None Past Medical Hx- Remote hx of rectal bleeding age 6 (negative coagulopathy workup) Past Surgical Hx- None FamHx–Non-contributory Meds –None Allergies –None Social Hx–Student, healthy, lives with family. No concern for child abuse

5. Review of Systems • Positive for nausea/vomiting

6. External Exam

7. Anterior Segment Exam

9. Posterior Segment Exam

10. CT Head Original vs 2 Days Later

11. CT Head Original vs 2 Days Later

12. CT Orbit Coronal Sagittal

13. Assessment/Plan • 13 yo male s/p hair-pulling trauma with large subgaleal hematoma, now with extension into left superior orbit, resulting in complete ophthalmoplegia and orbital compartment syndrome. • Emergent canthotomy/cantholysis was performed at bedside • Patient was taken to OR with Oculoplastics for emergent left anterior orbitotomy with hematoma evacuation

15. Subgaleal Hematomas • Bleeding in potential space between the thin fibrous galeaaponeurotica of the scalp and the periosteum covering the cranium • Occurs in two settings • Neonates with vacuum-assisted vaginal delivery • Childhood traumas (minor and major head trauma)

16. Subgaleal Hematomas • Orbital extension is very rare • In children, galealaponeurosis is loosely attached to the pericranium • Larger quantity of small emissary veins present compared to adults • Radial or tangential forces may cause rupture of these small vessels • Volume of emissary veins and thinner scalp in children makes them more susceptible to collect blood in subgaleal space

18. Subgaleal Hematomas • Hemorrhage in subgaleal space can accumulate and dissect to the orbital rim and extend subperiosteally • In children, there may be weaker attachments of periosto-galeal tissue to the bony orbit, allowing extension of blood • Prior reports of minor trauma associated • Hair pulling, hair braiding

19. Coagulopathy Risk? • Various coagulopathies have been associated with developing of subgaleal hematomas • Factor VII, IX, and XIII • Need to coordinate with hematology team to test for these

20. KEY POINTS • Subgaleal hematomas are more common in pediatric populations • Worsening subgaleal hematoma with proptosis should raise high suspicion of orbital extension and stat ophthalmological evaluation • Acute intervention with canthotomy/cantholysis, with possible surgical evacuation of hematoma, may be necessary to preserve vision • Thorough hematologic work-up is necessary

21. References • Puri S, Duff SM, Mueller B, PrendesM, Clark J.Hairpullingcausing vision loss: a case report. Hamlin H. Subgaleal hematoma caused by hair-pull. JAMA 1968;204:339. Orbit. 2018 May 4:1-4. • Edmondson SJ, Ramman S, Haram NH, Bisarya K, Fu B, Ong J, Akhavani M. Hair Today; Scalped tomorrow: Massive Subgaleal Haematoma Following Sudden Hair Pulling in an Adolescent in the Absence of Haematological Abnormality or Skull Fracture. J Craniofac Surg. 2026;27:1261-2 • Karcioglu ZA, Hoehn ME, Lin YP, Walsh J. Ocular involvement after subgaleal hematoma. J AAPOS. 2008 Oct;12(5):521-3. • Jenkins TL, Zheng CX, Murchison AP, Bilyk JR. Orbital Compartment Syndrome Following Post-Traumatic Subgaleal Hematoma. OphthalPlastReconstr Surg 33 (2), e33-e36. Mar-Apr 2017 • Chandrasekar, A., Daniela, L., Devia, Y., Julius, Ramachandra, S., Rajendran, A., Sa, G., S.Shubab, Scott, X., & Vaishnavi (2015). Subgaleal Bleed and Bilateral Proptosis as an Initial Manifestation of Mild Hemophilia a in a Child. Sri Ramachandra Journal of Medicine, Jan- June 2015, Vol.8, Issue 1 • Pope-Pegram LD, Hamill MB. . Post-traumatic subgaleal hematoma with subperiosteal orbital extension. Surv Ophthalmol. 1986 Jan-Feb;30(4):258-62. • Prakash S. Bilateral proptosis from a subgaleal hematoma. J Neurosurg 1990;72:835. • Adeloye A, Adeku EL. Subgaleal haematoma in head injuries. Int Surg 1975;60:263 • Vu TT, Guerrera MF, Hamburger EK, et al. Subgaleal hematoma from hair braiding: Case report and literature review. PediatrEmerg Care 2004;20:821-3 • GuirgisMF, Segal WA, Lueder GT. Subperiosteal orbital hemorrhage as initial manifestation of Christmas disease (factor IX deficiency). Am J Ophthalmol 2002;133:584–5.

22. Thank You • Dr. Clark

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