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Tahir MZ, Mirza FA, Thompson DNP, Hayward R. Early Intervention and Use of Autologous Grafts in Growing Skull Fractures Results in Better Outcomes: Experience From a Tertiary Pediatric Neurosurgery Center. Oper Neurosurg (Hagerstown) 2024; 27:279-286. [PMID: 38560818 DOI: 10.1227/ons.0000000000001130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 12/17/2023] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Growing skull fracture (GSF) is a rare complication of pediatric head trauma. Definitive treatment is surgical repair. We have attempted to assess whether use of autologous grafts for duraplasty and cranioplasty leads to better outcomes. We have also attempted to understand how timing of surgery might affect the degree of underlying damage to cortical tissue. METHODS This is a single-center retrospective observational study based on review from the Great Ormond Street Hospital Neurosurgery prospective surgical database. All patients undergoing surgery for GSF repair between 1991 and 2015 were included. Surgical techniques included split calvarial grafts in 4 patients, whereas rest had full-thickness bone grafting. In all cases with full-thickness graft, the donor site was covered with morselized bone chips mixed with fibrin glue (Salami technique). RESULTS Twenty-eight patients were identified (16 males, 12 females). The average age at the time of injury was 13 months. The mean duration of onset of symptoms from the time of injury was 4.4 months. The time interval from symptom onset to surgical repair was 5.92 months. Seven patients had Type I GSF (leptomeningeal cyst with minimal brain parenchyma), 13 had type II (hernia containing gliotic brain), and 8 had type III (porencephalic cyst extending through the skull defect into subgaleal space). Patients with delayed presentation had severe brain injury (Type III) and had more long-term complications (refractory epilepsy requiring temporo-occipito-parietal disconnection and development of hydrocephalus requiring ventriculoperitoneal shunt insertion). CONCLUSION Autologous pericranium for duraplasty and split-thickness bone graft or the Salami technique are recommended for cranioplasty. Synthetic materials should be used if the index operation fails or there are complications. Patients with high-risk findings should be identified at the time of initial presentation and followed up in clinic early to prevent onset of neurological deficit. Early repair is associated with better neurological outcomes.
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Affiliation(s)
- M Zubair Tahir
- Department of Pediatric Neurosurgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London , UK
| | - Farhan A Mirza
- Department of Neurological Surgery, Kentucky Neuroscience Institute (KNI), University of Kentucky, Lexington , Kentucky , USA
| | - Dominic N P Thompson
- Department of Pediatric Neurosurgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London , UK
| | - Richard Hayward
- Department of Neurosurgery, Great Ormond Street Hospital for Children NHS Foundation Trust, London , UK
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Choi JI, Kim SD. Pediatric Minor Traumatic Brain Injury : Growing Skull Fracture, Traumatic Cerebrospinal Fluid Leakage, Concussion. J Korean Neurosurg Soc 2022; 65:348-353. [PMID: 35468709 PMCID: PMC9082117 DOI: 10.3340/jkns.2021.0280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/16/2022] [Indexed: 11/27/2022] Open
Abstract
Traumatic brain injury (TBI) is a major public health issue that causes significant morbidity and mortality in the pediatric population. Pediatric minor TBIs are the most common and are widely underreported because not all patients seek medical attention. The specific management of these patients is distinct from that of adult patients because of the different physiologies in these age groups. This article focuses on minor TBIs, particularly growing skull fractures, traumatic cerebrospinal fluid leakage, and concussion.
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Affiliation(s)
- Jong-Il Choi
- Department of Neurosurgery, Korea University Ansan Hospital, Ansan, Korea
| | - Sang-Dae Kim
- Department of Neurosurgery, Korea University Ansan Hospital, Ansan, Korea
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Sharma G, Jain G, Shekhawat J, Chopra S, Sinha VD. An Unusual Presentation of Growing Skull Fracture with Sutural Diastasis. INDIAN JOURNAL OF NEUROTRAUMA 2020. [DOI: 10.1055/s-0040-1713460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractGrowing skull fracture (GSF) is a rare complication of childhood skull fractures, which is caused by progressive diastatic enlargement of the fracture line. Progressive swelling is the most common presenting feature. The most common site is the parietal region. Sutural diastasis is a rare site for development of GSF. Early treatment is must as they cause delayed onset neurological deficit and cranial asymmetry. The aim of this report is to discuss an unusual presentation of GSF with sutural diastasis and review of literature.
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Affiliation(s)
- Gaurav Sharma
- Department of Neurosurgery, SMS Medical College, Jaipur, India
| | - Gaurav Jain
- Department of Neurosurgery, SMS Medical College, Jaipur, India
| | | | - Sanjeev Chopra
- Department of Neurosurgery, SMS Medical College, Jaipur, India
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Yan XH, Qiu K, Gao Y, Ren J, Cheng D, Pang W, Song Y, Yang W, Yu R, Zhao Y. Growing Skull Fracture of Temporal Bone in Adults: A Case Report and Literature Review. EAR, NOSE & THROAT JOURNAL 2020; 99:654-657. [PMID: 32207331 DOI: 10.1177/0145561320914774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Growing skull fracture (GSF) is an uncommon post-traumatic complication, which accounts for approximately 0.05% to 1% of all skull fractures. Delayed diagnosis of GSF in adulthood is rare and often involved with a variety of neurological symptoms. Here, we reported an adult patient, with an interval of 17 years from initial head trauma to first diagnosis of GSF. The patient complained of short periods of fainting and bilateral visual hallucinations, with a hard palpable bulge around his right occipitomastoid suture region. Computed tomographic imaging demonstrated an arachnoid cyst extending into right mastoid cavity. Consequently, the delayed diagnosis of GSF was confirmed, and the patient was managed with duroplasty and cranioplasty. At the 8-month follow-up, the patient showed an uneventful postoperative recovery. A comprehensive literature review was also conducted, and a total of 70 GSF cases were identified and summarized. According to the literature review, patients with GSF generally have a history of head trauma in their childhood, and delayed diagnosis is a common situation. Diagnosis of GSF should include complete retrospective medical history, physical, and imaging examinations. Once the diagnosis is confirmed, cranioplasty accompanied with duroplasty might be the most effective way to relieve symptoms and prevent further damage.
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Affiliation(s)
- Xiao-Hong Yan
- Department of Oto-Rhino-Laryngology, 34753West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Ke Qiu
- Department of Oto-Rhino-Laryngology, 34753West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Yan Gao
- Department of Oto-Rhino-Laryngology, Chengdu Shangjin Nanfu Hospital, 34753West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Jianjun Ren
- Department of Oto-Rhino-Laryngology, 34753West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Danni Cheng
- Department of Oto-Rhino-Laryngology, 34753West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Wendu Pang
- Department of Oto-Rhino-Laryngology, 34753West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Yao Song
- Department of Oto-Rhino-Laryngology, 34753West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Wen Yang
- Department of Oto-Rhino-Laryngology, 34753West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Rong Yu
- Department of Oto-Rhino-Laryngology, 34753West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
| | - Yu Zhao
- Department of Oto-Rhino-Laryngology, 34753West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan, China
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7
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Abstract
Head injury in children is one of the most common causes of death and disability in the US and, increasingly, worldwide. This chapter reviews the causes, patterns, pathophysiology, and treatment of head injury in children across the age spectrum, and compares pediatric head injury to that in adults. Classification of head injury in children can be organized according to severity, pathoanatomic type, or mechanism. Response to injury and repair mechanisms appear to vary at different ages, and these may influence optimal treatment; however, much work is still needed before investigation leads to clearly effective clinical interventions. This is true both for the more severe injuries as well as those at the milder end of the injury spectrum, the latter of which have received increasing attention. In this chapter, neuroassessment tools for each age, newer imaging modalities including magnetic resonance imaging (MRI), and specific pediatric management issues, including intracranial pressure (ICP) monitoring and seizure prophylaxis, are reviewed. Finally, specific head injury patterns and functional outcomes relevant to pediatric patients are discussed. While head injury is common, the number of head-injured children is significantly smaller than the corresponding adult head-injured population. When divided further by specific ages, injury types, and other sources of heterogeneity, properly powered clinical research is likely to require large data sets that will allow for stratification across variables, including age. While much has been learned in the past several decades, further study will be required to determine the best management practices for optimizing recovery in individual pediatric patients. This approach is likely to depend on collaborative international head injury databases that will allow researchers to better understand the nuanced evolution of different types of head injury in patients at each age, and the pathophysiologic, treatment-related, and genetic factors that influence recovery.
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Abstract
Head injuries in children are common, comprising more than half of all injuries sustained. The mortality and morbidity associated with traumatic head injury in children is staggering, and the cumulative effect of such on the pediatric and general populations is propagated through related health care measures and subsequent socioeconomic burden. The majority of deaths due to trauma in children are caused by brain injury. This article reviews the evaluation and management of scalp injuries in the pediatric patient. The second portion addresses skull fractures, the specter of child abuse, management of acute fracture, and the phenomenon of growing skull fractures.
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Affiliation(s)
- Bruce B Horswell
- Charleston Area Medical Center, 830 Pennsylvania Avenue, Suite 302, Charleston, WV 25302, USA.
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Abstract
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.
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Affiliation(s)
- Xue-Song Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China.
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Pinto PS, Meoded A, Poretti A, Tekes A, Huisman TAGM. The unique features of traumatic brain injury in children. review of the characteristics of the pediatric skull and brain, mechanisms of trauma, patterns of injury, complications, and their imaging findings--part 2. J Neuroimaging 2012; 22:e18-41. [PMID: 22303964 DOI: 10.1111/j.1552-6569.2011.00690.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Traumatic brain injury (TBI) is a major cause of morbidity and mortality in children. The unique biomechanical, hemodynamical, and functional characteristics of the developing brain and the age-dependent variance in trauma mechanisms result in a wide range of age specific traumas and patterns of brain injuries. Detailed knowledge of the main primary and secondary pediatric injuries, which enhance sensitivity and specificity of diagnosis, will guide therapy and may give important information about the prognosis. In recent years, anatomical but also functional imaging methods have revolutionized neuroimaging of pediatric TBI. The purpose of this article is (1) to comprehensively review frequent primary and secondary brain injuries and (2) to give a short overview of two special types of pediatric TBI: birth related and nonaccidental injuries.
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Affiliation(s)
- Pedro S Pinto
- Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Hospital, Baltimore, MD, USA
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Abstract
The author describes 2 cases of children with growing skull fractures (GSFs). Surgical exploration of the widened fracture shortly after the head injury failed to reveal a dural tear because the neuroimaging studies (MR images, CT scans, and skull radiographs) had not been accurately interpreted, thereby allowing the development of a GSF at the site of the actual dural injury. In both cases, the dural and bony defect and the leptomeningeal cyst were successfully repaired. To prevent GSFs associated with progressive neurological deficit, seizure, ventricular porencephaly, and encephalomalacia, the author surgically explores wide skull fractures in young children with head injury whose MR images demonstrate brain herniation through the dura mater. The importance of a brief delay in surgical exploration is emphasized to allow cerebral edema to resolve and the patient's condition to become medically stabilized.
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Affiliation(s)
- Robert A Sanford
- Department of Pediatric Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Clinic, Memphis, Tennessee 38120, USA.
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12
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Vignes JR, Jeelani NUO, Jeelani A, Dautheribes M, Liguoro D. Growing skull fracture after minor closed-head injury. J Pediatr 2007; 151:316-8. [PMID: 17719947 DOI: 10.1016/j.jpeds.2007.04.041] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2006] [Revised: 02/26/2007] [Accepted: 04/19/2007] [Indexed: 11/20/2022]
Affiliation(s)
- Jean-Rodolphe Vignes
- Department of Neurosurgery A, CHU of Bordeaux, University of Bordeaux 2, Bordeaux, France.
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13
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Crocker M, Tawari G, Robertson F, Connor S, Bassi S. Growing skull fracture in the absence of a dural tear. Br J Neurosurg 2006; 20:97-9. [PMID: 16753626 DOI: 10.1080/02688690600682556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
A case of growing skull fracture associated with unrecognized extradural haematoma is presented together with the relevant radiology. The pathophysiology of growing skull fracture is reviewed in light of this previously unreported case.
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Affiliation(s)
- M Crocker
- Department of Neurosurgery, King's College Hospital, London, UK.
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Hamamcioglu MK, Hicdonmez T, Kilincer C, Cobanoglu S. Large intradiploic growing skull fracture of the posterior fossa. Pediatr Radiol 2006; 36:68-70. [PMID: 16249888 DOI: 10.1007/s00247-005-0012-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2005] [Revised: 08/15/2005] [Accepted: 08/16/2005] [Indexed: 10/25/2022]
Abstract
Growing skull fractures (GSFs) are rare complications of head injury and mostly occur in infancy and early childhood. Location in the posterior fossa and intradiploic development of a GSF is very uncommon. We report a 7-year-old boy with a large, 9 x 7 x 4-cm, occipital intradiploic GSF. The lesion developed progressively over a period of 5 years following a documented occipital linear fracture. This case of a GSF developing from a known occipital linear fracture demonstrates that a GSF may reach a considerable size and, although uncommon, intradiploic development and occipital localization of a GSF is possible.
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Affiliation(s)
- M Kemal Hamamcioglu
- Department of Neurosurgery, Faculty of Medicine, Trakya University, 22030 Edirne, Turkey.
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15
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Mierez R, Guillén A, Brell M, Cardona E, Claramunt E, Costa JM. [Growing skull fracture in childhood. Presentation of 12 cases]. Neurocirugia (Astur) 2003; 14:228-33; discussion 234. [PMID: 12872172 DOI: 10.1016/s1130-1473(03)70542-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Growing skull fractures (GSF) are rare complications of head injury (HI) in childhood. This entity consists of a skull fracture with an underlying dural tear that courses with a progressive enlargement of the fracture to produce a cranial defect. The pathophysiology and some aspects of its management are still controversial. In this review we present 12 patients diagnosedd and treated for a GSF at our institution between 1980 and 2002. 11 patients were under the age of 3 years and one patient was 5 years old at the moment of HI. The most common cause of injury was a fall from height. In the initial plain x-rayfilms, 11 patients showed a diastatic skull fracture and one patient only had a linear fracture. At this time, CT scan showed cortical contussion underlying the fracture in every case. The mean time between injury and presentation of GSF was 11.6 weeks. Diagnosis was made by palpation of the cranial defect and confirmed with skull x-rayfilms. The most frecuent location of GSF was in the parietal region. Associated lesions like hydrocephalus, encephalomalacia, lepto-menigeal cysts, brain tissue herniation and ipsilateral ventricular dilatation, were found in the preoperative CT or MRI. All patients underwent a dural repair with pericranium or fascia lata. The cranial defect was covered with local calvarial bone fragments in every case. Only one patient needed a cranioplasty with titanium mesh. Every child with a skull fracture must be followed until the fracture heals. Patients under the age of 3 years with a diastatic fracture and a dural tear, demostrated by TC or MRI, are more prone to develop GSF. In these cases, early repair must be adviced in order to prevent progressive brain damage.
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Affiliation(s)
- R Mierez
- Servicio de Neurocirugía. Hospital Sant Joan de Déu. Universidad de Barcelona, Barcelona. Spain
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Abstract
This article discusses all types of traumatic head injury in infants, children and adolescents. Neuroimaging patterns of injury help to make the precise diagnosis and assists in monitoring responses to therapy.
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Abstract
The imaging of head trauma has been one of the fundamental cornerstones of neuroradiology. As the practice of neuroimaging has matured, great strides have been made in the diagnostic as well as prognostic armamentarium available to physicians. Given the vast diversity of trauma mechanisms and clinical pathways, new advanced imaging technologies have had a lasting impact on the detection, description, and depiction of head trauma. Furthermore, these new tools are allowing the imaging specialist to function not only as an interpreter of what is seen but as a 21st century radiographic oracle. We present a comprehensive review of the imaging findings of sequlae of traumatic brain injury and the growing correlation of new neuroimaging techniques and neurotraumatic outcomes.
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Affiliation(s)
- Chi-Shing Zee
- Department of Radiology, Keck School of Medicine, University of Southern California, 1500 San Pablo Street, Los Angeles, CA 90033, USA.
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Gómez E, Carceller F, Chamorro-Pons M, García-Raya P. Growing cribiform plate fracture in a young adult patient: a case report. Otolaryngol Head Neck Surg 2001; 124:232-3. [PMID: 11226964 DOI: 10.1067/mhn.2001.112479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- E Gómez
- Department of Maxillofacial Surgery, University Hospital La Paz, 28046 Madrid, Spain
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