Cranio-cerebral erosion: delayed diagnosis and treatment

Growing skull fractures: guidelines for early diagnosis and surgical management

BACKGROUND

Growing skull fracture (GSF) is a rare complication of pediatric head trauma and causes delayed onset neurological deficits and cranial defect. GSF usually develops following linear fracture with underlying dural tear resulting in herniation of the brain. Early diagnosis and treatment are essential to avoid complications. However, there are no clear-cut guidelines for the early diagnosis of GSF. The present study was conducted to identify the criteria for the early diagnosis of GSF.

MATERIAL AND METHODS

From 2010 to 2015, all pediatric patients of head trauma with linear fracture were evaluated. Patients of age <5 years with cephalhematoma, bone diastasis of 4 mm or more with underlying brain contusion were subjected to contrast brain MRI to find out the dural tear and herniation of the brain matter. Patients with contrast MRI showing dural tear and herniation of the brain matter were considered high risk for the development of GSF and treated surgically within 1 month of trauma. Patients with contrast brain MRI not showing dural tear and herniation of the brain matter were regularly followed for any signs of GSF.

RESULTS

A total of 20 patients were evaluated, out of which 16 showed dural defects with herniation of the brain matter and were subjected to duraplasty. Four patients in which MRI did not show dural tear and herniation of the brain matter were regularly followed-up and have not shown any sign of GSF later on follow-up.

CONCLUSION

Early diagnosis of GSF can be made based on the four criteria, i.e., (1) age <5 year with cephalhematoma, (2) bone diastasis 4 mm or more (3) underlying brain contusion (4) contrast MRI showing dural tear and herniation of the brain matter. Dural tear with herniation of the brain matter is the main etiopathogenic factor for the development of GSF. Early diagnosis and treatment of GSF can yield a good outcome.

Surgical results of growing skull fractures in children: a single centre study of 43 cases

PURPOSE

Growing skull fractures are rare complications of traumatic skull fractures in children. The authors aim to share their experience in management of such lesions and analyse clinicoradiological features, surgical management and outcome in addition to prognostication factors.

MATERIALS AND METHODS

Retrospective study performed to include patients ≤18 years operated for growing skull fractures at our trauma centre from December 2007 to February 2014.

RESULTS

Forty-three children were operated. Mean age at presentation was 4.57 years (range 7 months-18 years). Mean duration of onset of symptoms from initial trauma was 3.34 months (2 days-24 months). Mean interval from symptom onset to surgical repair was 11.6 months (1 week-15 years). Progressive non-tender scalp swelling was the most common symptom and parietal, the most common location. Duraplasty alone was performed in four patients while combined duro-cranioplasty was performed in the rest. Mean follow-up duration was 31 months (4-72 months). Subdural hygroma was associated in six cases. Two patients expired; rest all survivors had good-to-excellent cosmetic outcomes.

CONCLUSIONS

Being the second largest series to date, it adds significant valuable contribution to this topic. Poor prognostic factors were age >8 years, females, large defects (>7 cm), severe head injury at initial trauma, defects crossing midline and delayed repair (>8 months). Delayed onset seizures and new onset/progression of pre-existing deficits can be indirect markers of evolution. Surgical repair with water-tight dural closure is the standard treatment. Emphasis on early treatment is highlighted which is probably beneficial in improving neurological deficits. Good-to-excellent outcomes are noted in majority, even in cases with delayed presentations.

Growing skull fracture stages and treatment strategy

OBJECT

A growing skull fracture (GSF) is a rare but significant late complication of skull fractures, usually occurring during infancy and early childhood. Delayed diagnosis and improper treatment could exacerbate this disease. The aim of this study was to introduce a new hypothesis about, describe the stages of, and discuss the treatment strategy for GSF.

METHODS

The authors performed a retrospective review of 27 patients with GSF, who were grouped according to 3 different GSF stages.

RESULTS

Over a period of 20 years, 27 patients with GSF (16 males and 11 females) were treated in the authors' department. The mean follow-up period was 26.5 months. Six patients were in the prephase of GSF (Stage 1), 10 patients in the early phase (Stage 2), and 11 in the late phase (Stage 3). All patients underwent duraplasty. All 6 patients at Stage 1 and 5 patients at Stage 2 underwent craniotomy without cranioplasty. Five patients at Stage 2 and all of the patients at Stage 3 underwent cranioplasty with autologous bone and alloplastic materials, respectively. Among all patients, 5 underwent ventriculoperitoneal shunt placement. Symptoms in all patients at Stages 1 and 2 were alleviated or disappeared, and the cranial bones developed without deformity during follow-up. Among patients with Stage 3 GSF, no obvious improvement in neurological deficits was observed. Three patients underwent additional operations because of cranial deformation or infection.

CONCLUSIONS

The authors identify the stages of GSF according to a new hypothesis. They conclude that accurately diagnosing and treating GSF during Stages 1 and 2 leads to a better prognosis.

Growing skull fracture in an adult nine years after blunt head trauma

Growing skull fracture (GSF) is an uncommon but well recognized complication of calvarial fracture in infancy and early childhood. The condition is rare in adults, and involvement of the skull base in this group of patients affects mostly the orbital roof. We present a patient with an unusual GSF involving the cribriform plate in a 37-year-old man who presented with late-onset epilepsy and recurrent meningitis 9 years after the initial trauma. Imaging studies revealed an associated intraethmoidal meningoencephalocele. The patient recovered well after a limited transcranial repair with preservation of olfactory function. A high index of suspicion should be exercised in the management of patients who present with these symptoms even many years after injury.