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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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McAvoy M, Hopper RA, Lee A, Ellenbogen RG, Susarla SM. Pediatric Cranial Vault and Skull Base Fractures. Oral Maxillofac Surg Clin North Am 2023; 35:597-606. [PMID: 37442667 DOI: 10.1016/j.coms.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
Cranial vault and skull base fractures in children are distinctly different from those seen in adults. Pediatric skull fractures have the benefit of greater capacity to remodel; however, the developing pediatric brain and craniofacial skeleton present unique challenges to diagnosis, natural history, and management. This article discusses the role of surgical treatment of these fractures, its indications, and techniques.
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Affiliation(s)
- Malia McAvoy
- Department of Neurosurgery; Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Craniofacial Center, Seattle Children's Hospital, Seattle, WA, USA
| | - Richard A Hopper
- Department of Neurosurgery; Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Craniofacial Center, Seattle Children's Hospital, Seattle, WA, USA
| | - Amy Lee
- Department of Neurosurgery; Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Craniofacial Center, Seattle Children's Hospital, Seattle, WA, USA
| | - Richard G Ellenbogen
- Department of Neurosurgery; Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Craniofacial Center, Seattle Children's Hospital, Seattle, WA, USA
| | - Srinivas M Susarla
- Department of Neurosurgery; Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Craniofacial Center, Seattle Children's Hospital, Seattle, WA, USA.
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Tan AP, Rasheed S, Sidpra J, Lim MC, James G, Oztekin O, Gonçalves FG, Mankad K. An algorithmic clinicoradiological approach to paediatric cranial vault lesions: distinguishing normal variants from pathologies. Br J Neurosurg 2023; 37:986-999. [PMID: 33960863 DOI: 10.1080/02688697.2021.1919599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/16/2021] [Indexed: 10/21/2022]
Abstract
Lesions of the paediatric cranial vault are diverse both in their presentation and aetiology. As such, they pose a diagnostic challenge to the paediatric neurosurgeon and neuroradiologist. In this article, we delineate the spectrum of paediatric calvarial pathology into four distinct groups: (1) lytic lesion(s); (2) focal sclerotic lesion(s); (3) diffuse cranial vault sclerosis; and (4) abnormal shape of the cranial vault. It is our aim that this more pragmatic, algorithmic approach may mitigate diagnostic uncertainty and aid the more accurate diagnosis of paediatric calvarial lesions.
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Affiliation(s)
- Ai Peng Tan
- Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Shabana Rasheed
- Department of Diagnostic Imaging, KK Children and Women's Hospital, Singapore, Singapore
| | - Jai Sidpra
- Developmental Biology and Cancer Section, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Mei Chin Lim
- Department of Diagnostic Imaging, National University Health System, Singapore, Singapore
| | - Greg James
- Department of Neurosurgery, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Ozgur Oztekin
- Department of Neuroradiology, Tepecik Education and Research Hospital, Izmir, Turkey
| | | | - Kshitij Mankad
- Department of Neuroradiology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
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Singhal GD, Atri S, Suggala S, Jaluka D, Singhal S, Shrivastava AK. Growing Skull Fractures; Pathogenesis and Surgical Outcome. Asian J Neurosurg 2021; 16:539-548. [PMID: 34660366 PMCID: PMC8477810 DOI: 10.4103/ajns.ajns_183_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 09/01/2018] [Accepted: 01/26/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND We performed a retrospective study of 67 patients and their data for radiological investigations by serial Xrays, computed tomography, magnetic resonance imaging, uniform surgical procedure of craniotomy. The results were analyzed to determine the natural course of the disease, anatomical changes at various intervals following trauma, and outcome of surgical procedure in terms of cranial reconstruction, seizures, and progress in neurological deficit. RESULTS Among 67 patients, 34 (50.74%) were male and 33 (49.26%) were female patients. About 86.67% of patients sustained the injury before the age of 3 years. Development of seizures in 28 patients (41.80%) is the most common symptom. In our study, 43.28% of patients (29 cases) had a combination of Type I and II of growing skull fracture. The dural defects confirmed in all cases were nearly twice (average 1.42) as large as the bone defects. All patients under the age of 3 years with diastatic skull fracture should be closely followed up and should be examined 2-3 months later to look for evidence of a growing skull fracture. Linear fractures and burst fractures in an infant with a scalp swelling must be corrected early to prevent a growing skull fracture. CONCLUSION Early management can avoid difficult surgical dissection and progressive neurological sequelae seen with delayed intervention. Surgical correction results in the prevention of brain shift and increase in meningocerebral cicatrices. Meticulous surgery and vigilant postoperative care reduce the morbidity and mortality. In our opinion, the autologous material is the best choice because of its tissue compatibility, convenience, inexpensiveness, and rare rate of infection.
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Affiliation(s)
- G D Singhal
- Department of Neurosurgery, G B Pant Hospital, New Delhi, India
| | - Sanjeev Atri
- Department of Neurosurgery, NIMS Medical College and Hospital, Jaipur, Rajasthan, India
| | - Sudheer Suggala
- Assistant Professor of Neurosurgery, Doctor PSIMS and RF, Vijayawada, Andhra Pradesh, India
| | - Dinesh Jaluka
- Department of Neurosurgery, G Kar Medical College and Hospital, Kolkata, India
| | - Shakti Singhal
- Department of Anesthesia, Gajara Raja Medical College, Gwalior, Madhya Pradesh, India
| | - A K Shrivastava
- Department of Neurosurgery, G B Pant Hospital, New Delhi, India
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5
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Zeitoun IM, Ebeid K, Soliman AY. Growing skull fractures of the orbital roof: a multicentric experience with 28 patients. Childs Nerv Syst 2021; 37:1209-1217. [PMID: 33029727 DOI: 10.1007/s00381-020-04918-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Growing skull fracture (GSF) is a rare condition that may complicate pediatric head trauma. Patients may present with delayed-onset neurological manifestations. AIM This study aims to highlight the different presentations, methods of evaluation, treatment modalities, and outcomes in patients with orbital roof GSF. METHODS This retrospective multicentric cohort study reviewed the hospital records of children with GSF who presented at the Craniomaxillofacial Plastic Surgery Department, and Neurosurgery Department with Otorhinolaryngology Department (Maxillofacial unit), from 2011 to 2020. The collected data included age, gender, delay, manifestations, findings of imaging techniques, surgical treatment, complications, and satisfaction of patients' parents. RESULTS Twenty-eight patients with orbital roof GSF were included in this study. Most of the patients (82.1%) were boys, and the mean (SD) age was 5 (2) years old. Head trauma was caused by falls in all cases. Clinical manifestations included eyelid swelling (75%), pulsatile proptosis (25%), headache (17.9%), and seizures (10.7%). The mean (SD) diameter of bony defects was 24.3 (8.7) mm. Duraplasty alone was performed in 57.1%, while dura-cranioplasty was done in 42.9% of patients. Dural reconstruction was done using pericranial graft in 82.1% and artificial grafts in 17.9% of patients. Most of the parents (95%) were absolutely satisfied. No mortalities or recurrence of symptoms were recorded. The median follow-up period after surgery was 3.9 years. CONCLUSION Orbital roof GSF should be considered among the differential diagnoses in pediatric patients with history of head trauma presenting with ocular and/or neurological manifestations. Duraplasty is mandatory in all cases, whereas cranioplasty is required mainly in cases with large bony defects more than 25 mm. Prognosis in most patients was good both subjectively and objectively.
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Affiliation(s)
- Ibrahim Mohamed Zeitoun
- Faculty of Dentistry, Alexandria University, 18 Koliat el tib st., Ramlah station, Alexandria, 21526, Egypt
| | - Kamal Ebeid
- Otorhinolaryngology Department, Faculty of Medicine, Tanta University, Tanta, 31527, Egypt
| | - Ahmed Y Soliman
- Neurosurgery Department Faculty of Medicine , Tanta University , 31527, Tanta, Egypt.
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Kulkarni AV, Dikshit P, Devi BI, Sadashiva N, Shukla D, Bhat DI. Unusual Complication of a Neglected Growing Skull Fracture. Pediatr Neurosurg 2021; 56:179-183. [PMID: 33626526 DOI: 10.1159/000513102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 11/16/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The growing skull fracture (GSF) is a rare complication seen after head injury in infants and young children. It occurs due to a wide skull defect with underlying dural defect and changes in pressure gradients within skull cavity. Neglected cases may develop progressive neurological deficits and complications after second head trauma. Case Discussion: We present a 14-year-old child who developed sudden-onset, diffuse, soft, fluctuant, circumferential swelling of the head after a road traffic accident. He had sustained a head injury at the age of 3-months leading to an asymptomatic soft swelling over the skull which was left untreated. Present CT scan of the brain showed a bony defect with ragged edges and cerebrospinal fluid (CSF) collection in subgaleal space circumferentially. He underwent exploration, duroplasty, and cranioplasty and had a good outcome. CONCLUSION Neglected GSF can rupture and cause diffuse subgaleal CSF collection. It should be managed with dural repair and cranioplasty.
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Affiliation(s)
- Akshay Vijay Kulkarni
- Department of Neurosurgery, National institute of Mental Health and Neurosciences, Bengaluru, India
| | - Priyadarshi Dikshit
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - B Indira Devi
- Department of Neurosurgery, National institute of Mental Health and Neurosciences, Bengaluru, India,
| | - Nishanth Sadashiva
- Department of Neurosurgery, National institute of Mental Health and Neurosciences, Bengaluru, India
| | - Dhaval Shukla
- Department of Neurosurgery, National institute of Mental Health and Neurosciences, Bengaluru, India
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You Y, Romero J, Diaz G, Herman J, Siu A, Evans R. Cranial floor fracture: A growing orbital roof fracture with encephalocele - Case Report. Int J Surg Case Rep 2020; 78:172-175. [PMID: 33359964 PMCID: PMC7758275 DOI: 10.1016/j.ijscr.2020.12.012] [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: 11/17/2020] [Revised: 12/02/2020] [Accepted: 12/02/2020] [Indexed: 11/26/2022] Open
Abstract
Orbital roof fractures are among the rarest of craniofacial fractures. Detailed craniofacial examination and high-resolution CT imaging is necessary for diagnosis. A challenging aspect of the fractures is their “growing” nature. A growing encephalocele can complicate the treatment of orbital roof fractures. Orbital roof fractures can become progressively worse secondary to brain swelling.
Orbital roof fractures are among the rarest of craniofacial fractures. The mechanism of injury is typically a high-impact blunt force vector directly to the orbit or forehead. Most patients are males between 20 and 40 years old, involved in motor vehicle accidents. Although most orbital roof fractures are managed conservatively, there is a significant risk of ophthalmologic and neurologic complications. Detailed craniofacial examination and high-resolution CT imaging is necessary for diagnosis. A multidisciplinary team approach is required for these challenging fractures.
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Affiliation(s)
- Yuchen You
- Graduate Medical Education, Community Memorial Health System, Ventura, CA, USA.
| | - Javier Romero
- Graduate Medical Education, Community Memorial Health System, Ventura, CA, USA
| | - Graal Diaz
- Graduate Medical Education, Community Memorial Health System, Ventura, CA, USA
| | - James Herman
- Department of General Surgery, Ventura County Medical Center, Ventura, CA, USA
| | - Alan Siu
- Ventura County Neuroscience Center, Ventura County Medical Center, Ventura, CA, USA
| | - Robin Evans
- Department of General Surgery, Ventura County Medical Center, Ventura, CA, USA
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Pediatric Skull Fracture Characteristics Associated with the Development of Leptomeningeal Cysts in Young Children after Trauma: A Single Institution's Experience. Plast Reconstr Surg 2020; 145:953e-962e. [PMID: 32332544 DOI: 10.1097/prs.0000000000006745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Currently, the pathogenesis of leptomeningeal cysts, also known as growing skull fractures, is still debated. The purpose of this study was to examine the specific skull fracture characteristics that are associated with the development of growing skull fractures and describe the authors' institutional experience managing this rare entity. METHODS A retrospective cohort study was performed that included all patients younger than 5 years presenting to a single institution with skull fractures from 2003 to 2017. Patient demographics, cause of injury, skull fracture characteristics (e.g., amount of diastasis, linear versus comminuted fracture), concomitant neurologic injuries, and management outcomes were recorded. Potential factors contributing to the development of a growing skull fracture and neurologic injuries associated with growing skull fractures were evaluated using univariate logistic regression. RESULTS A total of 905 patients met the authors' inclusion criteria. Of these, six (0.66 percent) were diagnosed with a growing skull fracture. Growing skull fractures were more likely to be comminuted (83.3 percent versus 40.7 percent; p = 0.082) and to present with diastasis on imaging (100 percent versus 26.1 percent; p < 0.001; mean amount of diastasis, 7.1 mm versus 3.1 mm; p < 0.001). Univariate logistic regression analysis confirmed the role of a comminuted fracture pattern (OR, 7.572) and the degree of diastasis (OR, 2.081 per mm diastasis) as significant risk factors for the development of growing skull fractures. CONCLUSIONS The authors' analysis revealed that fracture comminution and diastasis width are associated with the development of growing skull fractures. The authors recommend dural integrity assessment, close follow-up, and early management in young children who present with these skull fracture characteristics. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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9
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Non-Midline Frontal Encephalocele Presenting as Disappearing Dermoid. J Craniofac Surg 2019; 30:e506-e508. [PMID: 31756879 DOI: 10.1097/scs.0000000000005409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Congenital masses in the lateral brow are most commonly dermoid cysts and can often be excised surgically without additional investigation. These dermoids may rarely develop intracranial extension due to underlying bony erosions and become less prominent over time - a "disappearing dermoid." However, the authors present an unusual alternative case in which an off-midline frontal encephalocele initially presented as a firm irreducible mass but exhibited changing characteristics over time.
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Northam W, Chandran A, Quinsey C, Abumoussa A, Flores A, Elton S. Pediatric nonoperative skull fractures: delayed complications and factors associated with clinic and imaging utilization. J Neurosurg Pediatr 2019; 24:489-497. [PMID: 31470399 DOI: 10.3171/2019.5.peds18739] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 05/22/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Skull fractures represent a common source of morbidity in the pediatric trauma population. This study characterizes the type of follow-up that these patients receive and discusses predictive factors for follow-up. METHODS The authors reviewed cases of nonoperative pediatric skull fractures at a single academic hospital between 2007 and 2017. Clinical patient and radiological fractures were recorded. Recommended neurosurgical follow-up, follow-up appointments, imaging studies, and fracture-related complications were recorded. Statistical analyses were performed to identify predictors for outpatient follow-up and imaging. RESULTS The study included 414 patients, whose mean age was 5.2 years; 37.2% were female, and the median length of stay was 1 day (IQR 0.9-4 days). During 438 clinic visits and a median follow-up period of 8 weeks (IQR 4-12, range 1-144 weeks), 231 imaging studies were obtained, mostly head CT scans (55%). A total of 283 patients were given recommendations to attend follow-up in the clinic, and 86% were seen. Only 12 complications were detected, including 7 growing skull fractures, 2 traumatic encephaloceles, and 3 cases of hearing loss. Primary care physician (PCP) status and insurance status were associated with a recommendation of follow-up, actual follow-up compliance, and the decision to order outpatient imaging in patients both with and without intracranial hemorrhage. PCP status remained an independent predictor in each of these analyses. Follow-up compliance was not associated with a patient's distance from home. Among patients without intracranial hemorrhage, a follow-up recommendation and actual follow-up compliance were associated with pneumocephalus and other polytraumatic injuries, and outpatient imaging was associated with a bilateral fracture. No complications were found in patients with linear fractures above the skull base in those without an intracranial hemorrhage. CONCLUSIONS Pediatric nonoperative skull fractures drive a large expenditure of clinic and imaging resources to detect a relatively small profile of complications. Understanding the factors underlying the decision for clinic follow-up and additional imaging can decrease future costs, resource utilization, and radiation exposure. Factors related to injury severity and socioeconomic indicators were associated with outpatient imaging, the decision to follow up patients in the clinic, and patients' subsequent attendance. Socioeconomic status (PCP and insurance) may affect access to appropriate neurosurgical follow-up and deserves future research attention. Patients with no intracranial hemorrhage and with a linear fracture above the skull base do not appear to be at risk for delayed complications and could be candidates for reduced follow-up and imaging.
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Affiliation(s)
| | - Avinash Chandran
- 2Matthew Gfeller Sport-Related TBI Research Center, Department of Exercise and Sport Science; and
| | | | | | - Alex Flores
- 3School of Medicine, University of North Carolina, Chapel Hill, North Carolina
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Cheyuo C, Singh R, Lucke-Wold B, Serrano C. Growing Skull Fracture: Case Report after Rottweiler Bite and Review of the Literature. JOURNAL OF NEUROLOGY & NEUROPHYSIOLOGY 2018; 9. [PMID: 29888100 DOI: 10.4172/2155-9562.1000461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Growing skull fracture remains a rare but clinically significant complication of traumatic skull fractures in children less than 3 years of age. Dog attacks on children commonly cause head and neck injuries. We report the first case of growing skull fracture caused by a Rottweiler bite in a 21 days old neonate. Early diagnosis and surgical repair resulted in excellent outcome.
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Affiliation(s)
- Cletus Cheyuo
- Department of Neurosurgery, Ruby Memorial Hospital, West Virginia University, USA
| | - Rahul Singh
- Department of Neurosurgery, Ruby Memorial Hospital, West Virginia University, USA
| | | | - Cesar Serrano
- Department of Neurosurgery, Ruby Memorial Hospital, West Virginia University, USA
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12
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Reliability of Triage Nurses and Emergency Physicians for the Interpretation of the C-3PO Rule for Head Trauma in Children. J Emerg Nurs 2018; 44:164-168. [DOI: 10.1016/j.jen.2017.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 05/22/2017] [Accepted: 06/16/2017] [Indexed: 11/18/2022]
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14
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Singh I, Rohilla S, Siddiqui SA, Kumar P. Growing skull fractures: guidelines for early diagnosis and surgical management. Childs Nerv Syst 2016; 32:1117-22. [PMID: 27023392 DOI: 10.1007/s00381-016-3061-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 03/13/2016] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Ishwar Singh
- PT.BD Sharma University of Health Sciences Rohtak, Rohtak, Haryana, India.
| | - Seema Rohilla
- PT.BD Sharma University of Health Sciences Rohtak, Rohtak, Haryana, India
| | | | - Prashant Kumar
- PT.BD Sharma University of Health Sciences Rohtak, Rohtak, Haryana, India
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15
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Huang KT, Abd-El-Barr MM, Dunn IF. Skull Fractures and Structural Brain Injuries. HEAD AND NECK INJURIES IN YOUNG ATHLETES 2016:85-103. [DOI: 10.1007/978-3-319-23549-3_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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16
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Bir SC, Kalakoti P, Notarianni C, Nanda A. John Howship (1781-1841) and growing skull fracture: historical perspective. J Neurosurg Pediatr 2015; 16:472-6. [PMID: 26186359 DOI: 10.3171/2014.12.peds14484] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In the late 18th and early 19th centuries, Dr. John Howship, a pioneering British surgeon, described the clinical features and pathophysiology of various surgical disorders of the human body. His critical contributions to pediatric neurosurgery came in 1816 when he first described the features of an important childhood condition following head trauma, what he referred to as parietal bone absorption. This condition as depicted by Dr. Howship was soon to be christened by later scholars as traumatic cephalhydrocele, traumatic meningocele, leptomeningeal cyst, meningocele spuria, fibrosing osteitis, cerebrocranial erosion, and growing skull fracture. Nevertheless, the basic features of the condition as observed by Dr. Howship were virtually identical to the characteristics of the above-mentioned disorders. This article describes the life and accomplishments of Dr. Howship and his contributions to the current understanding of growing skull fracture.
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Affiliation(s)
- Shyamal C Bir
- Department of Neurosurgery, LSU Health Shreveport, Louisiana
| | - Piyush Kalakoti
- Department of Neurosurgery, LSU Health Shreveport, Louisiana
| | | | - Anil Nanda
- Department of Neurosurgery, LSU Health Shreveport, Louisiana
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17
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Jain S, Gandhi A, Sharma A, Mittal RS. Growing skull fracture with cerebrospinal fluid fistula: A rare case report and its management strategies. Asian J Neurosurg 2015; 10:229-31. [PMID: 26396614 PMCID: PMC4553739 DOI: 10.4103/1793-5482.161182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The growing skull fracture (GSF) occurs in younger age group as a sequel of trauma. The most common site of these lesions is parietal region. Here we are presenting a case of GSF of posterior fossa with cerebrospinal fluid (CSF) fistula. As per literature, we have not found a single case of GSF in the posterior fossa with CSF fistula. The aim of this presentation is discussing the unusual presentation of GSF and its management.
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Affiliation(s)
- Saurabh Jain
- Department of Neurosurgery, SMS Hospital, Jaipur, Rajasthan, India
| | - Ashok Gandhi
- Department of Neurosurgery, SMS Hospital, Jaipur, Rajasthan, India
| | - Achal Sharma
- Department of Neurosurgery, SMS Hospital, Jaipur, Rajasthan, India
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Gravel J, Gouin S, Chalut D, Crevier L, Décarie JC, Elazhary N, Mâsse B. Derivation and validation of a clinical decision rule to identify young children with skull fracture following isolated head trauma. CMAJ 2015; 187:1202-1208. [PMID: 26350911 DOI: 10.1503/cmaj.150540] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 07/30/2015] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND There is no clear consensus regarding radiologic evaluation of head trauma in young children without traumatic brain injury. We conducted a study to develop and validate a clinical decision rule to identify skull fracture in young children with head trauma and no immediate need for head tomography. METHODS We performed a prospective cohort study in 3 tertiary care emergency departments in the province of Quebec. Participants were children less than 2 years old who had a head trauma and were not at high risk of clinically important traumatic brain injury (Glasgow Coma Scale score < 15, altered level of consciousness or palpable skull fracture). The primary outcome was skull fracture. For each participant, the treating physician completed a standardized report form after physical examination and before radiologic evaluation. The decision to order skull radiography was at the physician's discretion. The clinical decision rule was derived using recursive partitioning. RESULTS A total of 811 patients (49 with skull fracture) were recruited during the derivation phase. The 2 predictors identified through recursive partitioning were parietal or occipital swelling or hematoma and age less than 2 months. The rule had a sensitivity of 94% (95% confidence interval [CI] 83%-99%) and a specificity of 86% (95% CI 84%-89%) in the derivation phase. During the validation phase, 856 participants (44 with skull fracture) were recruited. The rule had a sensitivity of 89% and a specificity of 87% during this phase. INTERPRETATION The clinical decision rule developed in this study identified about 90% of skull fractures among young children with mild head trauma who had no immediate indication for head tomography. Use of the rule would have reduced the number of radiologic evaluations by about 60%.
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Affiliation(s)
- Jocelyn Gravel
- Départements de pédiatrie (Gravel, Gouin), chirurgie (Crevier) and radiologie (Décarie), Centre hospitalier universitaire (CHU) Sainte-Justine, Université de Montréal; Department of Pediatrics (Chalut), Montréal Children's Hospital, McGill University, Montréal, Que.; Département d'urgence (Elazhary), Hôpital Fleurimont (CHU Sherbrooke), Université de Sherbrooke, Sherbrooke, Que.; Centre de recherche du CHU Sainte-Justine (Mâsse), Université de Montréal, Montréal, Que.
| | - Serge Gouin
- Départements de pédiatrie (Gravel, Gouin), chirurgie (Crevier) and radiologie (Décarie), Centre hospitalier universitaire (CHU) Sainte-Justine, Université de Montréal; Department of Pediatrics (Chalut), Montréal Children's Hospital, McGill University, Montréal, Que.; Département d'urgence (Elazhary), Hôpital Fleurimont (CHU Sherbrooke), Université de Sherbrooke, Sherbrooke, Que.; Centre de recherche du CHU Sainte-Justine (Mâsse), Université de Montréal, Montréal, Que
| | - Dominic Chalut
- Départements de pédiatrie (Gravel, Gouin), chirurgie (Crevier) and radiologie (Décarie), Centre hospitalier universitaire (CHU) Sainte-Justine, Université de Montréal; Department of Pediatrics (Chalut), Montréal Children's Hospital, McGill University, Montréal, Que.; Département d'urgence (Elazhary), Hôpital Fleurimont (CHU Sherbrooke), Université de Sherbrooke, Sherbrooke, Que.; Centre de recherche du CHU Sainte-Justine (Mâsse), Université de Montréal, Montréal, Que
| | - Louis Crevier
- Départements de pédiatrie (Gravel, Gouin), chirurgie (Crevier) and radiologie (Décarie), Centre hospitalier universitaire (CHU) Sainte-Justine, Université de Montréal; Department of Pediatrics (Chalut), Montréal Children's Hospital, McGill University, Montréal, Que.; Département d'urgence (Elazhary), Hôpital Fleurimont (CHU Sherbrooke), Université de Sherbrooke, Sherbrooke, Que.; Centre de recherche du CHU Sainte-Justine (Mâsse), Université de Montréal, Montréal, Que
| | - Jean-Claude Décarie
- Départements de pédiatrie (Gravel, Gouin), chirurgie (Crevier) and radiologie (Décarie), Centre hospitalier universitaire (CHU) Sainte-Justine, Université de Montréal; Department of Pediatrics (Chalut), Montréal Children's Hospital, McGill University, Montréal, Que.; Département d'urgence (Elazhary), Hôpital Fleurimont (CHU Sherbrooke), Université de Sherbrooke, Sherbrooke, Que.; Centre de recherche du CHU Sainte-Justine (Mâsse), Université de Montréal, Montréal, Que
| | - Nicolas Elazhary
- Départements de pédiatrie (Gravel, Gouin), chirurgie (Crevier) and radiologie (Décarie), Centre hospitalier universitaire (CHU) Sainte-Justine, Université de Montréal; Department of Pediatrics (Chalut), Montréal Children's Hospital, McGill University, Montréal, Que.; Département d'urgence (Elazhary), Hôpital Fleurimont (CHU Sherbrooke), Université de Sherbrooke, Sherbrooke, Que.; Centre de recherche du CHU Sainte-Justine (Mâsse), Université de Montréal, Montréal, Que
| | - Benoît Mâsse
- Départements de pédiatrie (Gravel, Gouin), chirurgie (Crevier) and radiologie (Décarie), Centre hospitalier universitaire (CHU) Sainte-Justine, Université de Montréal; Department of Pediatrics (Chalut), Montréal Children's Hospital, McGill University, Montréal, Que.; Département d'urgence (Elazhary), Hôpital Fleurimont (CHU Sherbrooke), Université de Sherbrooke, Sherbrooke, Que.; Centre de recherche du CHU Sainte-Justine (Mâsse), Université de Montréal, Montréal, Que
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Guler I, Buyukterzi M, Oner O, Tolu I. Post-traumatic leptomeningeal cyst in a child: computed tomography and magnetic resonance imaging findings. J Emerg Med 2015; 48:e121-2. [PMID: 25662419 DOI: 10.1016/j.jemermed.2014.12.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 10/22/2014] [Accepted: 12/21/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Ibrahim Guler
- Department of Radiology, Konya Research and Education Hospital, Konya, Turkey
| | - Meral Buyukterzi
- Department of Radiology, Konya Research and Education Hospital, Konya, Turkey
| | - Ozgur Oner
- Department of Radiology, Konya Research and Education Hospital, Konya, Turkey
| | - Ismet Tolu
- Department of Radiology, Konya Research and Education Hospital, Konya, Turkey
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Prasad GL, Gupta DK, Mahapatra AK, Borkar SA, Sharma BS. Surgical results of growing skull fractures in children: a single centre study of 43 cases. Childs Nerv Syst 2015; 31:269-77. [PMID: 25227164 DOI: 10.1007/s00381-014-2529-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 08/10/2014] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- G Lakshmi Prasad
- Department of Neurosurgery, JPNATC, All India Institute of Medical Sciences, New Delhi, India
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Carrière B, Clément K, Gravel J. Variation in the use of skull radiographs by emergency physicians in young children with minor head trauma. CAN J EMERG MED 2014; 16:281-7. [PMID: 25060081 DOI: 10.2310/8000.2013.131081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Minor head trauma in young children is a major cause of emergency department visits. Conflicting guidelines exist regarding radiologic evaluation in such cases. OBJECTIVE To determine the practice pattern among Canadian emergency physicians for ordering skull radiographs in young children suffering from minor head trauma. Physicians were also surveyed on their willingness to use a clinical decision rule in such cases. DESIGN/METHODS A self-administered email questionnaire was sent to all members of the Pediatric Emergency Research Canada (PERC) group. It consisted of clinical vignettes followed by multiple-option answers on the management plan. The study was conducted using the principles of the Dillman Tailored Design method and included multiple emailings to maximize the response rate. The research protocol received Institutional Review Board approval. RESULTS A total of 158 of 295 (54%) PERC members responded. Most participants were trained in pediatric emergency medicine and assessed more than 500 children per year. Imaging management for the vignettes was highly variable: 6 of the 11 case scenarios had a proportion of radiograph ordering between 20 and 80%. Ninety-five percent of respondents stated that they would apply a validated clinical decision rule for the detection of skull fracture in young children with minor head trauma. The minimum sensitivity deemed acceptable for such a rule was 98%. CONCLUSION Canadian emergency physicians have a wide variation in skull radiography ordering in young children with minor head trauma. This variation, along with the need expressed by physicians, suggests that further research to develop a clinical decision rule is warranted.
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Abstract
INTRODUCTION Growing skull fractures are rare complications of head injury in young children. Till date, growing skull fractures due to an underlying arrested hydrocephalus or subdural hygroma have not been reported. We are reporting two such rare cases. DISCUSSION A 12-year-old male who was a known case of arrested hydrocephalus sustained a mild head injury and was found to have a linear fracture. One month after the initial injury, a soft swelling was noted in the parietal region. Investigations revealed the dilated ventricular system communicating through a growing skull fracture with a subgaleal CSF collection. The patient underwent a ventriculoperitoneal shunt using a high-pressure shunt system. The patient died suddenly 48 h after the surgery. An 8-month-old female child sustained a mild head injury with a linear fracture in the parieto-occipital region. Two months later, the child presented with seizures and a soft, fluctuant swelling in the parieto-occipital region. Imaging revealed a frontoparietal subdural hygroma with mass effect that was communicating through a growing skull fracture with a subgaleal CSF collection. The patient underwent a subduroperitoneal shunt. The shunt tube was removed 3 months later as it protruded through the abdominal wound. Follow-up imaging studies revealed complete resolution of the subdural hygroma with healing of the growing skull fracture. CONCLUSIONS Growing skull fractures can occur as complications of mild head injury sustained in the setting of either arrested hydrocephalus or subdural hygroma. Hence, close follow-up of patients with skull fracture and arrested hydrocephalus/subdural hygroma is necessary for early diagnosis of growing skull fractures.
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Affiliation(s)
- Natarajan Muthukumar
- Department of Neurosurgery, Madurai Medical College, Muruganagam 138, Anna Nagar, Madurai, 625-020, India,
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Abstract
OBJECTIVE The objective of this study was to compare the sensitivity and specificity of 2- and 4-film x-ray series when interpreted by pediatric emergency medicine physicians in the diagnosis of skull fracture in children. METHODS A noninferiority crossover study was performed. The skull radiographs of the 50 most recent cases of skull fracture for which a 4-film radiography series was available and 50 controls matched for age were reviewed. Two modules, containing a random sequence of 2- and 4-film series of each child, were constructed to have all children evaluated twice (once with 2 films and once with 4 films). Pediatric emergency physicians evaluated both modules 2 to 4 weeks apart. The interpretation of the 4-film series by a pediatric radiologist served as the criterion standard. The sensitivity and specificity of the 2-film versus the 4-film skull x-ray series, in the identification of fracture, were compared. RESULTS Thirteen pediatric emergency physicians participated in the study. For sensitivity, the mean difference between the 2- and 4-view series was higher than the noninferiority margin of 0.055 with an absolute mean difference of 0.060 (4-view minus 2-view series) and a 1-sided 95% higher confidence limit of 0.099. However for specificity, the mean difference was within the margin with an absolute mean difference of 0.011 and a 1-sided 95% higher confidence limit of 0.033. CONCLUSIONS For children sustaining a head trauma, the 2-film skull radiography series is not as sensitive as the 4-film series in the detection of fracture, when interpreted by pediatric emergency physicians.
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Sahoo N, Kumar P, Rappai T. Growing skull fracture. Indian J Dent 2013. [DOI: 10.1016/j.ijd.2012.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Use of magnetic resonance imaging to identify the edge of a dural tear in an infant with growing skull fracture: a case study. Childs Nerv Syst 2012; 28:1951-4. [PMID: 22895681 DOI: 10.1007/s00381-012-1891-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 08/03/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE Growing skull fractures can be a challenging surgical problem facing pediatric neurosurgeons. The goal of this manuscript was to describe an effective surgical method used to treat a growing skull fracture. METHODS We present a case study of a 2-month-old boy who fell from his mother's arms and hit his head on the floor; he underwent X-ray, magnetic resonance (MR), and computed tomography (CT) imaging before cranioplasty with dural plasty. RESULTS X-ray performed on admission revealed a diastatic fracture with a gap of 8 mm in the right frontal bone and a linear fracture in the right occipital bone. X-ray performed 37 days after injury demonstrated that the gap had increased to 25 mm, and the patient was diagnosed with a growing skull fracture of the right parietal bone. Cranioplasty with dural plasty was performed on day 39. A combination of MR and CT images enabled the edge of the dural tear to be plotted on a three-dimensional image of the skull, and this was used to estimate the location of the edge of the dural tear on the scalp. CONCLUSIONS We achieved excellent outcomes in terms of bony coverage and dural plasty. The combination of MR and CT images may be recommended for surgical repair of growing skull fracture in children.
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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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Egozi D, Maor U, Ullmann Y. Complication of Full-Thickness Calvarial Burn in an Infant. J Burn Care Res 2011; 32:e92-6. [DOI: 10.1097/bcr.0b013e318217f9f0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chauvet D, Sainte-Rose C, Boch AL. [The mystery of prehistoric trepanations: Is neurosurgery the world eldest profession?]. Neurochirurgie 2010; 56:420-5. [PMID: 20869089 DOI: 10.1016/j.neuchi.2010.07.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Accepted: 07/05/2010] [Indexed: 10/19/2022]
Abstract
Trepanation is known to be the first surgical procedure ever performed. Its origins date from the Neolithic Age in Europe and the operation was particularly performed in South America at the Pre-Colombian era, a few thousand years later. Based on many archeological studies on trepanned skulls, we compare the differences and similarities of these two periods through epidemiological, topographical, and technical approaches. Signs of bony regeneration are assessed in an attempt to understand the postoperative survival of trepanned patients. The literature in surgery and archeology does not mention the possible relation between trepanations and growing skull fractures. However, it is reasonable to think that these cranial holes, occurring after a pediatric skull fracture, could mimic real trepanation orifices. The possible connections between these two entities are discussed. The etiological hypotheses on prehistoric trepanation are reviewed.
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Affiliation(s)
- D Chauvet
- Service de neurochirurgie, groupe hospitalier Pitié-Salpêtrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
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Intrauterine head stab wound injury resulting in a growing skull fracture: a case report and literature review. Childs Nerv Syst 2010; 26:377-84. [PMID: 19662424 DOI: 10.1007/s00381-009-0969-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Penetrating injuries of the gravid uterus are rare complications of pregnancy with gunshot wounds most common than stab wounds. Fetal head injury is an unusual sequela of these penetrating traumas. MATERIALS AND METHODS We describe the case of a 20-year-old pregnant woman stabbed at the lower abdomen at 30th weeks of gestation. She was nonsurgically managed by serial examination and continuous fetal monitoring. RESULTS Spontaneous vaginal delivery occurred at term with good maternal and fetal outcome. The newborn examination revealed a right temporal swelling interpreted as a subcutaneous hemangioma. At 2 years and 6 months of life, the child was led to our attention with a pulsating bulge in the right temporal region. Clinical examination and imaging were indicative of a typical growing skull fracture. The child underwent neurosurgical procedure for repairing of the dural tear and bone defect according to the senior author's personal technique, described in details, with a good neurological and esthetic outcome. CONCLUSION Thirty-two cases of stab wounds to the pregnant uterus have been reported to date in medical literature with two cases of fetal head injury.Growing skull fractures are rare complications of head injury and only one case has been described in the perinatal period following blunt trauma to the mother's abdomen 2-3 weeks before birth.
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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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Meier JD, Dublin AB, Strong EB. Leptomeningeal cyst of the orbital roof in an adult: case report and literature review. Skull Base 2009; 19:231-5. [PMID: 19881904 DOI: 10.1055/s-0028-1096206] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To present the case of a leptomeningeal cyst involving the orbital roof in an adult. DESIGN Case report and literature review. SETTING Tertiary referral center. SUMMARY A 47-year-old female with a remote history of a skull fracture at 3 years of age presented with increasing headaches and retro-orbital pain. A computed tomogram and magnetic resonance image revealed a leptomeningeal cyst of the orbital roof. RESULTS Only one previous leptomeningeal cyst of the orbital roof has been reported in an adult. Surgical excision of the lesion was performed and follow-up imaging 18 months after the operation revealed no evidence of recurrence. CONCLUSION Although extremely rare, adult patients can develop growing skull fractures or leptomeningeal cysts of the orbital roof. Such lesions should be included in the differential diagnosis when a patient presents with orbital pain or exophthalmos and a history of head trauma as a child.
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Affiliation(s)
- Jeremy D Meier
- Department of Otolaryngology-Head and Neck Surgery, University of California Davis Medical Center, Sacramento, CA
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Reconstruction of growing skull fracture with in situ galeal graft duraplasty and porous polyethylene sheet. J Craniofac Surg 2009; 20:1245-9. [PMID: 19553832 DOI: 10.1097/scs.0b013e3181acdfaf] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE In growing skull fractures with large calvarial defects, it is difficult to use autografts for reconstruction and it requires alternative materials for cranioplasty. In this report, the authors describe their experience and introduce reconstruction of the growing skull fractures' defects with a porous polyethylene sheet (Medpor) and with a novel technique of duraplasty with in situ galeal graft, which avoid the potentially risky dissection and exposure of brain tissue. The goal of this study was to clarify effective surgical methods and to provide the rationale for these techniques. METHODS We performed this technique on 8 patients with large calvarial defects resulting from growing skull fractures. The skin flap was retracted, leaving the galeal plane adherent to the underlying defect. After removing the bony edges and exposing the underlying retracted dural margins, duraplasty was performed by suturing the galeal tissue left in situ on the defect of the dural margins. Bone reconstruction was performed by placing porous polyethylene sheet (Medpor). CONCLUSIONS Duraplasty with in situ galeal tissue is a simple, safe, and effective technique to reconstruct dural defects in growing skull fracture, which avoids the risky dissection of the brain tissue. Also, by using Medpor, growing skull fractures can be effectively reconstructed with good cosmetic results.
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Mohindra S, Mukherjee KK, Chhabra R, Gupta R. Orbital roof growing fractures: a report of four cases and literature review. Br J Neurosurg 2009; 20:420-3. [PMID: 17439096 DOI: 10.1080/02688690601101580] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Trivial injuries among paediatric patients are usually underestimated. Such injuries may account for delayed problems such as growing fractures of skull vault. Growing fracture of the orbital roof is rarely reported. Four cases of paediatric cranial trauma with growing orbital roof fractures are presented. Three cases required only dural repair, while the fourth patient underwent both duraplasty and cranioplasty, due to a large orbital roof defect. At follow-up, all had satisfactory outcome. Trivial injuries among children should be evaluated with caution. The development of orbital symptomatology should ask for a complete radiological survey. The orbital roof growing fractures are potentially important cause of orbital problems. The dural repair alone, usually provides satisfactory outcome, while calvarial bone graft may be of help in cases with large bony defects. Early diagnosis and management of such cases may prevent permanent neurological deficits.
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Affiliation(s)
- S Mohindra
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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Singhal A, Steinbok P. Operative management of growing skull fractures: a technical note. Childs Nerv Syst 2008; 24:605-7. [PMID: 18157539 DOI: 10.1007/s00381-007-0552-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2007] [Indexed: 11/25/2022]
Abstract
OBJECTS Growing skull fractures can be a challenging surgical problem facing the pediatric neurosurgeon. The goal of this manuscript is to clarify effective surgical methods and to provide the rationale for these techniques. METHODS We describe the surgical techniques for treatment of growing skull fractures. We clarify the underlying concepts, with respect to dural closure and repair of bony defects, that have led to these techniques. CONCLUSIONS With effective surgical technique, the pediatric neurosurgeon can effectively treat growing skull fractures, with excellent outcomes in terms of bony coverage and cosmesis.
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Affiliation(s)
- Ashutosh Singhal
- Division of Neurosurgery, Department of Pediatric Surgery, British Columbia Children's Hospital, University of British Columbia, 4480 Oak Street, Room K3-159, Vancouver, British Columbia, Canada, V6H 3V4.
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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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Josan VA, Sgouros S, Walsh AR, Dover MS, Nishikawa H, Hockley AD. Cranioplasty in children. Childs Nerv Syst 2005; 21:200-4. [PMID: 15616854 DOI: 10.1007/s00381-004-1068-2] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The objective was to assess the outcome and complications associated with different cranioplasty implant materials in children. MATERIALS AND METHODS A retrospective review was conducted of 28 consecutive cranioplasties carried out on 24 children between 1994 and 2001 (age range, 9 months to 15 years; minimum follow-up 18 months). The indications were: defect from previous craniectomy for trauma, tumour, infection or evacuation of haematoma (n=21), intradiploic dermoid cysts (n=2), growing fractures (n=4) and residual bony defect following craniofacial reconstruction (n=1). The materials used were: patient's craniectomised bone flap (n=16), split calvarial graft (n=8), acrylic (n=3) and titanium (n=1). All patients were assessed for bony fixation, cosmesis, wound healing and flap infection. RESULTS There was no mortality and 18% morbidity (n=5: 3 infected flaps, 1 sterile wound dehiscence and 1 sterile wound discharge; overall infection rate 10%). Out of the 14 patients who had their own craniectomised bone flaps implanted initially, 3 became infected (2 in patients with bilateral defects) necessitating flap removal. Two of these were successfully re-implanted. No donor or recipient bone flap complications were seen in the 8 split calvarial grafts, wound discharge was seen in 1, requiring wound toilet. No complications were seen with acrylic or titanium cranioplasties. CONCLUSION In this series, the use of the patients' own craniectomised flap had a low infection rate, and was mainly seen in patients who had bilateral flaps re-implanted soon after removal. There were no complications arising from the use of split calvarial and allograft material. Use of autologous implant material should be preferred whenever possible due to obvious resource and biological advantages, and can even be re-implanted if infected.
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Affiliation(s)
- V A Josan
- Department of Neurosurgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
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Chaudhuri Z, Saxena R. Vertical Gaze Palsy in a case with Growing Skull Fracture and Porencephalic Cyst. Eye (Lond) 2005; 19:232-4. [PMID: 15218515 DOI: 10.1038/sj.eye.6701436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Menkü A, Koç RK, Tucer B, Kurtsoy A, Akdemir H. Growing skull fracture of the orbital roof: Report of two cases and review of the literature. Neurosurg Rev 2003; 27:133-6. [PMID: 14614595 DOI: 10.1007/s10143-003-0311-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2003] [Accepted: 08/26/2003] [Indexed: 11/28/2022]
Abstract
In this report, the authors describe two cases of growing fracture of the orbital roof. The aim is to draw attention to this rare complication and discuss the role of three-dimensional computed tomography in radiological findings and surgical planning. Relevant literature is also reviewed.
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Affiliation(s)
- Ahmet Menkü
- Department of Neurosurgery, Erciyes University Medical School, 38039, Kayseri, Turkey.
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Zegers B, Jira P, Willemsen M, Grotenhuis J. The growing skull fracture, a rare complication of paediatric head injury. Eur J Pediatr 2003; 162:556-557. [PMID: 12802685 DOI: 10.1007/s00431-003-1256-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2002] [Accepted: 04/18/2003] [Indexed: 11/25/2022]
Affiliation(s)
- Bas Zegers
- Department of Paediatrics 435 and Paediatric Neurology, University Medical Centre St. Radboud, 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Petr Jira
- Department of Paediatrics 435 and Paediatric Neurology, University Medical Centre St. Radboud, 9101, 6500 HB, Nijmegen, The Netherlands
| | - Michel Willemsen
- Department of Paediatrics 435 and Paediatric Neurology, University Medical Centre St. Radboud, 9101, 6500 HB, Nijmegen, The Netherlands
| | - Jan Grotenhuis
- Department of Paediatrics 435 and Paediatric Neurology, University Medical Centre St. Radboud, 9101, 6500 HB, Nijmegen, The Netherlands
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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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Escudero R, Pérez I, Roldán F, Canabal A. Fractura craneal evolutiva. Extensión intradiploica occipital del quiste leptomeníngeo. RADIOLOGIA 2001. [DOI: 10.1016/s0033-8338(01)76976-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gelabert González M, García Pravos A, Fernández Villa J, Cutrín Prieto J, Pérez Muñuzuri A. Quiste leptomeníngeo postraumático de larga evolución. Neurocirugia (Astur) 2000. [DOI: 10.1016/s1130-1473(00)70967-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Minor head injury is a common occurrence in children of all ages; however, controversy exists regarding the management of these children. Reports of neurologically intact children with intracranial injuries have caused many to recommend cautious management, while the infrequency of serious intracranial injuries after minor head trauma have prompted others to be less conservative. Based on recent literature reports, strategies for the management of children with minor head trauma are presented.
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Affiliation(s)
- K S Quayle
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
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