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BMJ Case Rep. 2014 Jul 4;2014. pii: bcr2013203080. doi: 10.1136/bcr-2013-203080.

Subdural haemorrhage and severe coagulopathy resulting in transtentorial uncal herniation in a neonate undergoing therapeutic hypothermia.

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Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.


Therapeutic hypothermia has been shown to be efficacious for improving long-term neurodevelopmental outcomes following perinatal asphyxia. Thus, cooling protocols have been adopted at most tertiary neonatal centres. We present a case of a term neonate who underwent therapeutic whole-body cooling for hypoxic ischaemic encephalopathy following a difficult forceps delivery. She abruptly deteriorated, exhibiting signs of transtentorial uncal herniation and severe disseminated intravascular coagulopathy. CT of the head confirmed a life-threatening subdural haematoma and a concealed skull fracture. Hypothermia has been shown to impair haemostasis in vivo and thus may potentially exacerbate occult haemorrhages in a clinical setting. Newborns that require instrument-assisted delivery are a particularly high-risk group for occult head injuries and should undergo careful clinical assessment for fractures and intracranial haemorrhage prior to initiation of therapeutic hypothermia.

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