A distinction between epidural and subdural hematoma may not be possible by CT or MRI of the brain in some cases. The choice of treatment in hypotonic neonates with an epidural or a subdural hematoma is determined by the clinical manifestations and CT or MRI findings. Hypotonic neonates that are stable or improving should be observed. Neonates with evidence of mental status deterioration, focal cranial nerve findings, or evidence of midline shift or herniation on CT or MRI of the brain should be managed surgically. Patients with epidural or subdural hematomas and associated cephalohematomas should be managed by drainage of the cephalohematoma through a burr hole. If this maneuver fails or a cephalohematoma is not present, direct intracranial drainage should be performed.
Subarachnoid hemorrhage refers to blood between the arachnoid and the piamater. The blood surrounds the brain parenchyma and also follows the piamater into the sulci and fissures. Subarachnoid hemorrhage is usually an incidental finding in neonates with hypotonia. Parenchymal (Figure 109.1 [B]) and intraventricular (Figure 109.1 [C]) hemorrhages are occasionally found in hypotonic neonates. Magnetic resonance imaging of neonates with brain trauma should include the cervicomedullary junction because of the possibility of rostral cervical spine trauma.

Figure 109.1.— [A] Epidural bleeding, small intraparenchymal bleed on the opposite frontal hemisphere and subarachnoid bleed. [B] Intraventricular hemorrhage around the ventricles, intraparenchymal blood, and cerebromalacia in the right occipital lobes. [C] Intraventricular blood in the occipital horns of the lateral ventricles.