Growing skull fracture in childhood. A recurrent case treated by shunt operation

Endoscopic-assisted Duraplasty with Collagen Matrix for Growing Skull Fracture: A Case Report

Growing skull fracture (GSF) is a rare complication of pediatric head injury. Early diagnosis and immediate surgical intervention are required for the prevention of irreversible brain damage. Surgical management involves water-tight closure of the dural defect and commonly uses autologous materials because of tissue compatibility; however, a large skin flap and craniotomy are necessary to harvest the autologous materials and repair the dural defect. We describe a successful case of endoscopic-assisted duraplasty using collagen matrix in a female infant suffering from early phase GSF. A 4-month-old female infant presented with a GSF. We surgically treated her because the fracture width progressively expanded 6 days post-injury. A zigzag skin incision was made, and the extent of the skull fracture and dural laceration was observed using an endoscope. Utilizing the collagen matrix, duraplasty was performed to completely seal the dural defect. Subsequently, cranioplasty was performed and the opposite sides of the fracture margins were drawn and bonded by nylon suture. Postoperatively, the patient did not develop any complication or experience recurrence. This is the first report of duraplasty using collagen matrix in GSF, and the collagen matrix can be used as a dural substitute. This novel technique was safe and a less invasive surgical approach for treating patients with GSF.

Pediatric Skull Fracture Characteristics Associated with the Development of Leptomeningeal Cysts in Young Children after Trauma: A Single Institution's Experience

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.

Prevention of recurrence post leptomeningeal cyst repair

Leptomeningeal cysts, which are cystic collections filled with cerebrospinal fluid, are rare complications following pediatric head trauma and surgical correction of craniosynostosis. These cysts develop due to cerebrospinal fluid pulsations and brain growth that cause expansion of the dural tears. Although primary repair of the dural defect is the definitive treatment, the risk of cyst recurrence remains. Factors that increase this risk include syndromic craniosynostosis, hydrocephalus, increased intracranial pressure, and inadequate duraplasty/cranioplasty. Here, we report the successful treatment of a child with a complex leptomeningeal cyst on one hemisphere, Crouzon syndrome, and hydrocephalus who showed no cyst recurrence over 2 years of follow-up. We have also reviewed the literature for predictors of post-repair cyst recurrence and preventive surgical techniques in patients with high risk of recurrence.

Posttraumatic intraventricular arachnoid cyst accompanied by pseudomeningoencephalocele in a child

Growing skull fracture (GSF) is a rare complication of head trauma. A posttraumatic intraventricular arachnoid cyst (AC), neither isolated nor accompanied by a GSF has not been reported previously. A seven-year-old girl was admitted after a severe head injury with a separated right parieto-occipital fracture and contusion. She responded well to conservative therapy. Seven weeks after discharge, she was re-admitted with a large parieto-occipital pseudomeningoencephalocele due to herniation of cerebrospinal fluid and neural tissue to the subgaleal space through the widened fracture defect, an extra-axial cyst at the posterior interhemispheric space and an intraventricular cystic mass. She underwent open surgery, and the intraventricular cystic mass was totally removed. The histological findings were consistent with an AC. One week after dural repair, hydrocephalus developed, and a ventriculo-peritoneal shunt was inserted. She did well during two-year follow-up. The present case is unique as an intraventricular AC following head trauma. When an intraventricular cystic lesion is encountered after severe head trauma, the possibility of an AC should be considered; especially with neighboring contused neural tissue and leptomeningeal cyst formation.

[Growing skull fracture in childhood. Presentation of 12 cases]

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.

Cranio-cerebral erosion: delayed diagnosis and treatment

Cranio-cerebral erosion is a well-known complication of calvarian fracture with underlying dural tear and cerebral injury in infancy and early childhood. The anatomy, pathogenesis and natural evolution of these lesions remain obscure. The common clinical symptoms are seizures, focal neurological deficits, impairment of consciousness and a soft subgaleal mass. Three patients of cranio-cerebral erosion who underwent delayed surgery in their adult lives are presented to illustrate the common and uncommon features, and their long-term outcome is discussed.

Traumatic leptomeningeal cyst in an adult: a case report and review of the literature

BACKGROUND

Traumatic leptomeningeal cyst as a complication of skull fractures was initially thought to occur primarily in the pediatric population. The occurrence of a traumatic leptomeningeal cyst in the adult population is rare.

CASE DESCRIPTION

A lump in the right parietal region of this 53-year-old man prompted a computed tomography (CT) scan. The patient denied any symptoms and was in good health. Examination confirmed a firm, nontender, nonpulsatile mass in the right parietal region of the skull. The CT scan demonstrated a 4 x 3 cm area of irregular bone destruction involving both the inner and outer table of the skull. At operation a distinctly raised paper-thin outer table was noted, and underneath was a soft, tan-colored mass, which measured approximately 2 x 2 cm and was connected to the underlying brain through a 1 cm dural defect. The extradural portion of the mass was amputated, the dura repaired with a pericranium patch, the skull defect was repaired with a split thickness bone graft, and the final pathology was congruent with gliotic brain.

CONCLUSION

Although rare, this case demonstrates a traumatic leptomeningeal cyst in an adult.

Untreated growing cranial fractures detected in late stage

OBJECTIVE

Because the great majority of published cases of treated growing cranial fractures (GCFs) involved infants and children, the natural evolution of untreated GCFs is not well known. The question of whether untreated GCFs may cause progressive neurological deficits is controversial.

METHODS

This retrospective study is of GCFs treated between 1989 and 1997. Nine patients (eight male patients and one female patient; median age, 20.5 yr) with GCFs who underwent surgical intervention during the late stage are presented. The dural and cranial defects were repaired, and additional decompressive surgical procedures (cyst fenestration, n = 6; cyst excision, n = 1; cyst excision with cystoperitoneal shunting, n = 2) were performed for all patients. This is the largest of the published series.

RESULTS

All of the patients had histories of severe head trauma that occurred during childhood. The average age at the time of the onset of symptoms was approximately 13.1 years, and the interval between head injury and first symptom ranged from 8 to 13 years. All of the patients had lytic lesions in the cranium. Headache was the most common symptom, and of eight patients, seven improved completely and one improved partially. One of four epileptic patients was seizure-free postoperatively. None of the paresis improved, except in one patient.

CONCLUSION

We conclude that untreated GCFs may cause delayed onset neurological manifestations in addition to cranial growth asymmetry. GCFs, discovered incidentally in adolescence or adulthood without any neurological deficits, should be operated on as soon as feasible to prevent further brain destruction. Cranioplasty with dural repair, in addition to cyst fenestration, should be considered as the essential procedure for the treatment of these lesions.

Enlarging skull fractures in children

Large skull fractures are conventionally followed radiographically until healing occurs. Fractures which enlarge or remain unhealed are commonly termed "leptomeningeal cysts" or "growing skull fractures". This study of ten children with this injury and a review of the literature shows that a true leptomeningeal cyst is seldom present and that skull fractures do not "grow". Moreover, careful history-taking and physical examination will correctly identify all enlarging or unhealed skull fractures of childhood without the need for plain radiographs or computed tomography of the skull.

Pathogenesis and treatment of growing skull fractures

BACKGROUND

Growing skull fractures are poorly understood complications of pediatric skull fractures.

METHODS

A retrospective review of skull fractures at our institution from 1980-1993 revealed 10 patients with growing skull fractures. The age at injury ranged from 1-144 months, with 9 of 10 patients being under one year of age. The etiology of these fractures included falls, motor vehicle accidents, and child abuse. On average, growth of the fracture was diagnosed 14 months after the initial injury.

RESULTS

Six patients have had magnetic resonance imaging (MRI) with one demonstrating leptomeningeal cyst herniation, two having brain herniation, and three having both brain parenchyma and leptomeningeal cyst herniation. All patients had malacic cortex underlying the fracture, but there was no evidence of intracranial hypertension. Nine patients have undergone craniotomy with excision of granulation tissue and gliotic brain, dural repair, and cranioplasty using surrounding normal skull. There were no surgical complications or recurrences.

CONCLUSIONS

Brain/leptomeningeal cyst herniation through a dural rent, without MRI evidence of increased intracranial pressure, implicates physiologic growth and brain cerebrospinal fluid (CSF) pulsations as the cause of fracture enlargement.

Growing skull fracture in a patient with cerebral hemiatrophy

A growing skull fracture or leptomeningeal cyst most commonly occurs in children under the age of 3 years, and is extremely rare in adults. The reason for a growing skull fracture is usually a dural tear in association with the fracture. This paper presents an 18-year-old mentally retarded patient with cerebral hemiatrophy (Dyke-Davidoff-Masson syndrome) associated with a growing skull fracture in the ipsilateral hemicranium, in whom not only a dural tear but also the ipsilaterally displaced and dilated lateral ventricle due to the original disease apparently contributed to the development of growing skull fracture.