What is the management for a 60-year-old female with computed tomography (CT) brain findings of soft tissue swelling, subcutaneous contusion, and hematoma in the right parieto-occipital region?

Management of Soft Tissue Swelling with Subcutaneous Contusion and Hematoma in Right Parieto-Occipital Region

This 60-year-old female with CT findings of soft tissue swelling, subcutaneous contusion, and hematoma in the right parieto-occipital region requires conservative management with close monitoring, as these are superficial scalp injuries without intracranial pathology that typically resolve spontaneously. 1

Initial Assessment and Risk Stratification

Confirm the absence of intracranial injury on CT scan. The CT findings describe soft tissue swelling and subcutaneous hematoma, which are external to the skull and do not represent intracranial pathology such as subdural or epidural hematomas. 2, 1

Critical Clinical Evaluation Points:

• Assess Glasgow Coma Scale score - If GCS is 15 with no loss of consciousness, amnesia, or focal neurological deficits, the patient is at minimal risk for delayed intracranial complications. 2

• Evaluate for skull fracture - Review the CT scan specifically for any fracture lines in the parieto-occipital region, as skull fractures increase the risk of intracranial injury 20-fold and may warrant neurosurgical consultation. 2

• Check anticoagulation status - Patients on warfarin, NOACs, or antiplatelet agents beyond aspirin have a 3.9% versus 1.5% risk of intracranial hemorrhage and require more cautious management. 1

• Document mechanism of injury - High-risk mechanisms (fall from height, high-speed motor vehicle collision) warrant closer observation even with superficial findings. 2

Conservative Management Protocol

For isolated soft tissue hematoma without intracranial injury, implement the following:

• Apply ice packs to the affected area for the first 24-48 hours to reduce swelling and pain. 3

• Elevate the head of bed to 30 degrees to facilitate venous drainage and reduce hematoma expansion. 2

• Administer simple analgesics such as acetaminophen for pain control; avoid NSAIDs if there is any concern for bleeding expansion. 4

• Avoid aspiration or needle puncture of the subgaleal hematoma initially, as most resolve spontaneously and intervention carries infection risk. 3

Monitoring and Follow-Up

Discharge is appropriate if the patient meets all of the following criteria: 1

• GCS score of 15 with normal neurological examination
• No intracranial pathology on CT scan
• Reliable caregiver available for home monitoring
• Not on anticoagulation therapy

Mandatory Discharge Instructions:

Provide both written and verbal instructions at a sixth- to seventh-grade reading level with the following return precautions: 1

• Worsening or severe headache
• Repeated vomiting (more than once)
• Increasing confusion or abnormal behavior
• Difficulty waking up or increased sleepiness
• Seizures or convulsions
• Weakness or numbness in arms or legs
• Unequal pupils or vision changes
• Clear or bloody fluid from nose or ears

Do not recommend frequent waking or pupil checks at home for patients with negative intracranial CT findings, as evidence shows this is unnecessary and causes patient distress. 1

Indications for Admission or Extended Observation

Admit the patient if any of the following are present: 2, 1

• Any intracranial hemorrhage on CT scan (subdural, epidural, subarachnoid, or intraparenchymal)
• GCS score less than 15
• Focal neurological deficits
• Active anticoagulation therapy
• Unreliable social situation or no caregiver available
• Skull fracture, particularly if depressed or basilar

Surgical Intervention Considerations

Surgical evacuation of subgaleal hematoma is rarely indicated but should be considered if: 3

• Hematoma continues to expand despite conservative measures
• Significant cosmetic deformity develops
• Signs of infection (erythema, warmth, purulent drainage)
• Persistent pain unresponsive to analgesics

For refractory cases, endovascular coil embolization of feeding vessels followed by percutaneous aspiration has shown success in recent case reports, offering a less invasive alternative to open surgical drainage. 3

Expected Clinical Course

Most subgaleal hematomas resolve spontaneously within 2-4 weeks with conservative management. 3 The hematoma may initially increase in size over the first 24-48 hours before stabilizing and gradually resorbing. 5

Arrange outpatient follow-up in 1-2 weeks to assess hematoma resolution and ensure no delayed complications have developed. 1

Critical Pitfalls to Avoid

Do not confuse subgaleal hematoma with intracranial subdural hematoma - The CT description specifies "soft tissue swelling with subcutaneous contusion," which is external to the skull, not intracranial. 2, 5

Do not perform unnecessary repeat CT scans unless the patient develops new neurological symptoms or deterioration in mental status. 2, 1

Do not discharge patients on anticoagulation without neurosurgical consultation even with negative initial CT, as they remain at higher risk for delayed intracranial hemorrhage. 1