A 7-year-old girl, who was previously well, presented with complaints of scalp swelling. Two days prior to presentation, she had pain during combing of hairs, when her mother noticed swelling over the scalp and the swelling gradually increased in size over the next two days. There was no history of trauma, or family history suggestive of either bleeding disorder or coagulopathy. She was not on any medications, and had not undergone any surgical procedures.

On examination, she was conscious, alert, and had stable vitals. Neurologic examination and other systemic examinations were unremarkable. Local examination of the scalp revealed diffuse non-tender boggy swelling over the left parietal area. Skin over the swelling was normal. Computed tomography (CT) of head showed subgaleal bleed without skull fracture and intracranial pathology. Complete blood count, coagulation profile, factor XIII and VWF levels were normal.

As the child was hemodynamically stable, no neurosurgical intervention was required. Parents were counselled regarding the possible complications such as infections, calcification and further bleeding. The swelling was noted to decrease in size during follow up.

Subgaleal hematomas occurring beyond the neonatal period are rare and usually secondary to significant head trauma. Either tangential (blunt) or radial (pulling) forces cause shearing and rupture of emissary veins traversing the subgaleal space. Subgaleal hematoma has been reported following relatively minor trauma such as hair braiding or sudden hair pulling [1-3]. They are usually small, self-limiting in nature, remain localized, and resolve spontaneously and are usually conservatively managed. As this child presented with significant swelling, coagulation abnormality was considered as there was no history of trauma. As her investigations were unremarkable and she was hemodynamically stable, she was treated conservatively and the swelling resolved completely within two weeks. Edmondson, et al. [4] have previous reported a patient with delayed presentation of a massive subgaleal hematoma in an adolescent following a seemingly innocuous episode of hair pulling, in the absence of underlying hematological or anatomical abnormality [3].

In conclusion, although subgaleal bleed beyond neonatal period is rare, it can happen and the patient has to be investigated with neuroimaging to look for the skull fracture and hematoma extension, and investigated to rule out rare coagulation disorders, as subgaleal bleed due to hair pulling is a diagnosis of exclusion.

1. Scheier E, Guri A, Balla U. Subgaleal haematoma due to hair pulling: Review of the literature. Acta Paediatr. 2019;108: 2170-74.

2. Sellin JN, Moreno A, Ryan SL, et al. Children presenting in delayed fashion after minor head trauma with scalp swelling: Do they require further workup. Childs Nerv Syst. 2017;33: 647-52.

3. Vu TT, Guerrera MF, Hamburger EK, Klein BL. Subgaleal hematoma from hair braiding: Case report and literature review. Pediatr Emerg Care. 2004;20:821-3.

4. Edmondson SJ, Raman S,　Pachachi-Haram N, et al. Hair Today; Scalped Tomorrow: Massive subgaleal hematoma following sudden hair pulling in an adolescent in the absence of haematological abnormality or skull fracture. J Craniofacial Surg. 2016;27:1261-62.