Surgical Treatment of Ossified Cephalhematoma

Progressive vascular tumor in infant: A case report and literature review of PIK3CA vascular malformation

PURPOSE

Vascular anomalies are classified as either vascular tumors or vascular malformations. Vascular malformations can be difficult to diagnose and treat in the pediatric population and can masquerade as malignant processes. Understanding the genetics behind vascular malformations can lead to identification of specific mutations which can be treated with targeted immunotherapy.

METHODS

Our case presents a pediatric patient with progressively enlarging vascular malformation despite multiple surgical resections and systemic medical treatments who underwent genetic evaluation and was found to have PIK3CA mutation.

RESULTS

After identification of PIK3CA mutation, our patient was successfully treated with the p110ɑ-specific inhibitor, alpelisib, with both shrinkage of malformation on follow-up imaging as well as gains in her developmental milestones.

CONCLUSION

Progressive vascular malformations in the pediatric population can be hard to diagnose and treat and are thought to arise from somatic mutations. Our case highlights a patient with progressive malformation despite multiple surgical resections who was successfully treated with targeted immunotherapy after proper identification of genetic mutation.

Surgical Treatment of Ossified Cephalhematoma in Young Child

Cephalhematoma is a subperiosteal collection of blood. The lesion generally spontaneously resolves, but if cephalhematoma persists beyond this period, it typically begins to ossify and may require surgical treatment for correction. The incidence of ossified cephalhematoma is rare, and its pathogenesis is unclear. There have been reports of surgical treatment of ossified cephalhematoma in newborns and infants, but few reports in 5-year-old children. We experienced the surgical treatment of an ossified cephalhematoma in a 5-year-old boy. We performed periosteal reattachment with onlay bone autograft. Follow-up examination at 2 years revealed a good cosmetic result and a computed tomography scan showed excellent reconstitution of the contour of the skull.

Head Injury during Childbirth

Head injuries are the most common type of birth injuries. Among them, most of the injuries is limited to the scalp. and the prognosis is good enough to be unnoticed in some cases. Intracranial injuries caused by excessive forces during delivery are rare. However, since some of them can be fatal, it is necessary to suspect it at an early stage and evaluate thoroughly if there are abnormal findings in the patient.

Management of Calcified Cephalohematoma of Infancy: The University of Michigan 25-Year Experience

BACKGROUND

Cephalohematoma of infancy is the result of a subperiosteal blood collection that usually forms during birth-related trauma. A small proportion of cephalohematomas can calcify over time, causing a permanent calvarial deformity that is only correctable with surgery. The authors present a technique for the excision and reconstruction of calcified cephalohematoma and their management experience over the past 25 years.

METHODS

All patients with a diagnosis of calcified cephalohematoma between 1994 and 2019 were identified. Patients were included if the diagnosis was confirmed by a pediatric plastic surgeon or a neurosurgeon. All patients underwent surgical evaluation followed by surgical intervention or observation. Patient demographics and potential risk factors for both surgical and nonsurgical groups were compared using chi-square or Fisher's exact test. Additional data were collected for the surgical cohort.

RESULTS

Of 160 infants diagnosed with cephalohematoma, 72 met inclusion criteria. Thirty patients underwent surgical treatment. There was no significant difference in demographics, baseline characteristics, or potential risk factors between the operative and nonoperative groups. Mean age at the time of surgery was 8.6 months. Twenty-one surgical patients (70 percent) required inlay bone grafting. All surgery patients had improvement in calvarial shape. The main risk of surgery was blood loss requiring transfusion [eight patients (26.7 percent)]. Thirteen percent of patients experienced minor complications.

CONCLUSIONS

This series of 72 children with calcified cephalohematomas, 30 of whom required surgical intervention, is one of the largest to date. The technique presented herein demonstrated excellent surgical outcomes by restoring normal cranial contours and was associated with a low complication profile.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Ossified Encapsulated Cephalhematoma

ABSTRACT

Ossified cephalhematoma is a rare congenital condition that may be found if newborn cephalhematoma is not resolved. Here, however, the authors report an exceptional case of an 8-month-old baby presenting with an ossified cephalhematoma in the right parieto-occipital area. Pre-operative imaging showed a calcified subperiosteal hematoma. He underwent hematoma excision with bone contouring procedures. A histopathological study showed hemosiderin-laden macrophages with blood and pseudocyst walls. The authors also discuss the possible pathogenesis of the ossified cephalhematoma and its treatment.

Preoperative cephalhematoma size measured with computed tomography predicts intraoperative bleeding in pediatric patients undergoing cranioplasty

Background

Cranioplasty for the treatment of cephalhematomas in small infants with limited blood volume is challenging because of massive bleeding. This study aimed to elucidate the correlation between cephalhematoma size and intraoperative blood loss and identify criteria that can predict large intraoperative blood loss.

Methods

We reviewed the medical records of 120 pediatric patients aged less than 24 months who underwent cranioplasty for treatment of a cephalhematoma. The cephalhematoma sizes in preoperative brain computed tomography (CT) were measured using ImageJ.

Results

Pearson correlation showed that the cephalhematoma size in the pre-operative brain CT was weakly correlated with intraoperative blood loss (Pearson coefficient = 0.192, P = 0.037). In a multivariable logistic regression analysis, a cephalhematoma size greater than 113.5 cm³ was found to be a risk factor for large blood loss. The area under the curve in the receiver operating characteristic plot of the multivariable model was 0.714 (0.619–0.809).

Conclusions

A cephalhematoma size cutoff value of 113.5 cm³, as measured in the preoperative CT imaging, can predict intraoperative blood loss exceeding 30% of the total body blood volume. The establishment of a transfusion strategy prior to surgery based on cephalhematoma size could be useful in pediatric cranioplasty.

Observational Case Analysis of Neonates With Large Cephalohematoma

Introduction

Cephalohematomas in the newborn period are related to the accumulation of blood between the bone and periosteum as a result of a series of adverse conditions during labor. The optimal approach to cephalohematoma cases is still unclear. In this study, we aimed to present the follow-up data of 94 newborns with a cephalohematoma size of >50 mm and a higher risk of ossification. 

Methods 

This is a single-center, non-randomized, prospective, observational study conducted from May 2014 to May 2019. Records of all newborns with cephalohematoma were reviewed in terms of gender, birth weight, cephalohematoma region, transverse/vertical diameter of the lesion, delivery method, and rate of ossification. 

Results

The girl-to-boy ratio was 53/41, with a mean gestational age of 38.3±1.4 weeks and a mean birth weight of 3,300±800 grams. The mean transverse/vertical diameter of cephalohematoma was 59±9 mm. Cephalohematoma was completely resorbed at the first-month control visits in 72 (76.6%) cases, whereas nine (9.57%) had an ossified cephalohematoma. The ossification was completely or partially resorbed in these at the end of the one-year follow-up. 

Conclusion

Hence, we suggest that an early intervention is not required in the routine treatment of cases with hematomas with a size of >50 mm in size unless otherwise stipulated with clinical indications. 

Temporal Evolution of Imaging Findings in Ossified Cephalohematoma

BACKGROUND

Cephalohematoma is collection of blood between skull and periosteum that is confined by cranial sutures. Cephalohematomas usually resorb spontaneously within the first month of life; however, if it fails to resolve, ossified cephalohematoma may form.

METHODS

Clinical archiving system and picture archiving and communication system were retrospectively reviewed for cases of birth-related cephalohematoma. Cases of ossified cephalohematomas identified on imaging were retrieved from this subset of patients. Cross-sectional imaging findings in patients with ossified cephalohematomas were evaluated for location, size of the hematoma, and contours of the inner lamella.

RESULTS

Out of 115 cases of cephalohematoma, 7 cases had imaging findings consistent with ossified cephalohematoma. All ossified cephalohematomas were located parietally, with size ranging between 18 and 55 mm and the thickness of the outer rim of calcification ranging between 1.5 and 4.8 mm. The contour of inner lamella in relation to the surrounding normal cranial vault was normal in 5 cases, and inner lamella was depressed in 2 cases.Three patients had follow-up imaging available for demonstration of changes in ossified cephalohematoma. The first case was an 11 day-old boy with a cephalohematoma with no signs of calcification at the time of initial imaging. Follow-up at 2 months of age showed partial regression of hematoma cavity with marked calcification at the hematoma walls. The second case was a 3 month-old boy with ossified cephalohematoma at initial imaging. Follow-up imaging at 7 months of age showed almost total regression of hematoma cavity, and approximation of inner and outer lamella with increased thickness of the cranial vault. The third case was a 1 month-old boy with ossified cephalohematoma at initial imaging that totally resolved without residual increased bone thickness at 21-month follow-up.

CONCLUSION

These 3 cases demonstrate the variability in temporal changes that may occur in ossified cephalohematomas.

Early needle aspiration of large infant cephalohematoma: a safe procedure to avoid esthetic complications

Cephalohematoma is a common pathology in newborns. Observation is the primary treatment for most patients with small uncomplicated cephalohematoma. Conversely, a large cephalohematoma can lead to calcification with unesthetic local deformation or deformational plagiocephaly. The objective of the study was to evaluate the iatrogenic risk associated with early puncture under local anesthesia and oral sucrose. This is a retrospective study of 67 consecutive newborns followed at Montpellier University Hospital, France, between 2010 and 2017. Large cephalohematoma was defined on the basis of the bump projection. Due to the uncertainty of the spontaneous resorption and the risk of calcification after 4 weeks which render the needle aspiration ineffective, puncture was performed between 2 and 4 weeks of life after coagulation evaluation and ultrasound of the skull and scalp. Puncture was performed in 43 boys (64%) and 24 (36%) girls between day 15 and day 30 after birth. The cephalohematoma maximal projection measured by ultrasound ranged from 9 to 13 mm (Q1,Q4) with a median value of 12 mm. No puncture-related complication was recorded during the intervention and at the 1-month follow-up visit.Conclusion: In newborns with large and persistent unesthetic cephalohematoma, puncture under local anesthesia with oral sucrose can be safely proposed between day 15 and day 30 after birth.What is Known:• Infant cephalohematoma is a frequent pathology of newborns, consisting of a traumatic subperiosteal hematoma of the skull. Most cephalohematomas are small and require no treatment because they spontaneously disappear within the first month.• Large and non-resorptive cephalohematomas may have significant esthetic and functional consequences.What is New:• Early puncture under local anesthesia is a safe, effective, and rapid procedure, decreasing the risk of persistent skull deformities.• Puncture can be proposed for newborns with a large (high projection and/or high angle connection) persistent anesthetic cephalohematoma, between day 15 and day 30, before spontaneous calcification.

Calcified cephalohematoma as an unusual cause of EEG anomalies: case report

Cephalohematoma, one of the most common neonatal head injuries, generally undergoes spontaneous resorption. When calcified, it may cause cranial vault distortion and depression of the inner skull layer, although it remains asymptomatic. Surgery, indeed, is usually performed for cosmetic purposes. For these reasons, the long-term effects of calcified cephalohematoma (CC) are widely unknown. The authors report the case of an 11-year-old girl with a persistent calcified CC causing skull deformity and delayed electroencephalography (EEG) anomalies. These anomalies were detected during routine control EEG and were not clinically evident. The young girl underwent surgical removal of the CC for cosmetic purpose. The EEG abnormalities disappeared after surgery, thus reinforcing the hypothesis of a correlation with the brain "compression" resulting from the CC. To the best of the authors' knowledge this is the first time that CC-associated EEG anomalies have been described: even though these anomalies cannot be considered an indication for surgery, they merit late follow-up in case of skull deformity.

Ossified Cephalhematoma: An Unusual Cause of Calvarial Mass in Infancy

Cephalhematomas occurring in newborn usually resolve within a month. Rarely, they tend to ossify and present as hard scalp swelling. Unless one is aware of this possibility, this condition may be misinterpreted as bony tumor and cause needless apprehension to parents as well as the treating physician. A suspicion that ossified cephalhematoma (OC) could present in such a manner supported by careful history taking and relevant imaging (X-ray/computed tomography) would help in appropriate evaluation of this benign condition. The management of OC is controversial. Occasionally, they undergo spontaneous remodeling. Those with secondary craniosynostosis and/or disfigurement are treated surgically. Simple ossified lesions with no significant cosmetic issues may be conservatively tackled. We report such a case in a 3-month-old child. The other management options are briefly discussed.

Ossification of subperiosteal hematoma: the potential of periosteal osteogenesis in cranioplasty

BACKGROUND

Subperiosteal hematoma is the accumulation of blood between the periosteum and the skull, which commonly occurs in the neonatal period but rarely in other ages. Subperiosteal hematoma can be self-absorbed in most cases and occasionally may cause ossification.

MATERIALS AND METHODS

This study reports a case of subperiosteal hematoma formed in a 16-year-old adolescent boy after a minor trauma. Because the hematoma did not disappear for more than a month after the trauma, the patient was treated with multiple hematoma punctures. However, the hematoma recurred and led to ossification. Finally, the patient underwent surgical treatment.

RESULTS

Finally, the ossification associated with the hematoma was treated through surgery. The head contour recovered normally.

CONCLUSIONS

The occurrence of hematoma ossification in the 16-year-old patient suggests that the periosteum has great potential for osteogenesis. This is likely caused by the joint action of some active factors in the blood and a certain tension of the hematoma on the local periosteum. This case provides the following thoughts. (1) A subperiosteal hematoma that has not been absorbed after 1 month should be treated promptly to avoid ossification. Once ossification has occurred, the hematoma should be treated surgically. (2) The potential for periosteal osteogenesis is great, which may provide a new thought for cranioplasty.

Pediatric head trauma

Head injury in children accounts for a large number of emergency department visits and hospital admissions. Falls are the most common type of injury, followed by motor-vehicle-related accidents. In the present study, we discuss the evaluation, neuroimaging and management of children with head trauma. Furthermore, we present the specific characteristics of each type of pediatric head injury.

Cavernous hemangiomas of the cranial vault in infants: a case-based update

BACKGROUND

Mass lesions arising in the scalp or the cranial vault of children require a significant diagnostic work-up but their nature, in most instances, can only be clarified after histopathological study. Tumors of osseous consistency or merging from within cranial bones are seldom susceptible of fine needle aspiration biopsy and require excision. Ossified cephalhematoma is a rare entity that is usually related to perinatal or accidental trauma. Exceptionally, ossified cephalhematoma has a non-traumatic origin and arises from a different condition, as vascular tumor or malformation.

DISCUSSION

Cavernomas of the skull are infrequent and occur in middle-aged individuals. Skull cavernomas in infants lack the sunburst radiographic pattern seen in adults and may present as a bone-like tumor whose appearance is identical to that of ossified cephalhematoma. A literature search showed only two previous reports of patients younger than 1 year with skull cavernomas presenting with associated ossified cephalhematomas. We hypothesize that this type of skull cavernomas are congenital in origin and that they manifest precociously due to the occurrence of early bleeding.

CASE ILLUSTRATION

We report a 12-month-old boy presenting with a hard tumor arising on his right parietal bone that was present since birth. After diagnostic work-up, the bone tumor and the associated intraosseous hematoma were removed. Interestingly, the source of the hematoma was a cavernous hemangioma originating in the skull.

CONCLUSIONS

Calvarial cavernous hemangiomas may bleed precociously, even before birth, and manifest as large intraosseous hematomas. Differential diagnosis against ossified cephalhematoma can only be established through histopathological study.

Congenital cavernous hemangioma of the calvaria. Case report

The authors present the case of a 6-month-old infant with a cavernous hemangioma of the parietal bone and discuss the radiological, operative, and pathological features and differential diagnosis of these extremely rare lesions in infants. Only 1 case of an infant with a calvarial cavernous hemangioma without intracranial invasion has previously been reported, and that case involved a 4 month old. Although a cavernous hemangioma of the calvaria is extremely rare in the newborn, this condition should be included in the differential diagnosis of calvarial lesions. During surgical treatment of calvarial cavernous hemangiomas, utmost attention should be paid to avoid blood loss, which could be fatal in infants.

Early neurosurgical treatment of cephalhaematomas-personal experience and review of the literature

OBJECTIVE

A group of 123 children suffering from cephalhaematoma were treated at the Clinic of Pediatric Surgery, Orthopaedics and Traumatology in Brno Faculty Hospital within 5 years.

MATERIALS AND METHODS

One hundred and nine patients were treated by aspirations and 14 patients underwent neurosurgery; it means that all patients were treated with determined surgical intervention. The surgery was indicated and performed very early, so that the calvaria bone under the ossified cephalhaematoma was intact and there was no need of cranioplasty. The results were excellent, as all patients were treated successfully and no infectious or other complications were observed in all cases.

CONCLUSION

Based on our results, we suggest a more radical therapeutic approach and to perform aspirations if the cephalhaematoma is diagnosed. If calcification develops, early neurosurgery is much easier, allows to achieve better cosmetic result and cranioplasty is not necessary. Early indicated and performed surgery treatment of cephalhaematomas can be considered as simple, safe and effective procedure, therefore a more radical therapeutic approach and early surgical treatment of cephalhaematomas should be recommended.

Sagittal craniosynostosis combined with ossified cephalhematoma--a tricky and demanding puzzle

INTRODUCTION

Four cases of sagittal synostosis combined with ossified cephalhematoma prompted the authors to present the data and to discuss the implications. Large cephalhematoma of the vertex at birth with subsequent ossification occurred in all with final sizes of 6.5-10 by 4.0-5.5 by 0.8-1.8 cm. At surgery with 2-6 months, the mean skull index was 64.75, sagittal suture completely closed, and a disfiguring bony mass present in all.

DISCUSSION

In three of the original cohort of 106 sagittal synostoses, ossified cephalhematoma was removed in one piece together with the suture. In contrast to pathogenesis of common parietal cephalhematomas, cephalhematoma in sagittal synostosis is rather induced by periosteal detachment of the midline by strong shearing forces because molding is hindered in the lateral direction. Frequent and fast complete ossification is possibly directed by the same local factors (e.g., Noggin) which lead to premature fusion of cranial sutures. Some treatment principles of ossified cephalhematoma in sagittal synostosis may be applied to surgery of common types.

Caput succedaneum and cephalohematoma: the cs that leave bumps on the head

Caput succedaneum and cephalohematoma are conditions that rarely evoke much concern in the NICU but deserve more attention. This article examines the two conditions, reviews the literature, discusses possible complications, and leaves the reader with a heightened awareness of these seemingly benign lesions.

Simple excision and periosteal reattachment for the treatment of calcified cephalhematoma

Until now, calcified cephalhematoma has been treated by excision of the lesion and the use of an onlay autograft. The authors report their use of a less complicated alternative, simple excision and periosteal reattachment, in a 3-month-old male infant. They excised the calcified cap of cephalhematoma and reattached the periosteum to the exposed bone surface instead of using an onlay autograft technique. A follow-up CT scan demonstrated a smooth skull contour and good cosmetic appearance. The authors note that this is the first report of the successful use of simple excision and periosteal reattachment for the treatment of a case of calcified cephalhematoma in which there was a depressed area after the calcified cap was removed. They conclude that in cases of calcified cephalhematoma it may be unnecessary to perform a complicated cranioplasty with bone harvested from the top of the calcification.

Ossified cephalhematoma

Ossified cephalhematoma is a rare clinical entity and a pathological curiosity. Even though cephalhematoma is frequently encountered, ossified cephalhematoma is seen only sporadically and is restricted to only few case reports in the literature. Its pathogenesis is unclear, and the clinical course is different in neonates and juveniles. The risk factors are known, but why it gets ossified in some cases is not understood. We report a case of ossified cephalhematoma which developed in a 10-week-old male child in the right parietal region and discuss its possible pathogenesis.

Calcified Cephalohematoma

While calcified cephalohematoma is eminently correctable, a clear description of indications for surgery and surgical techniques are currently lacking in the literature. In this paper we propose a simple classification and an algorithm for the management of cephalohematomas. Three patients were treated for large calcified parietal cephalohematomas. Craniectomy and cranioplasty were performed with excellent outcome. Cranioplasty was performed with the cap radial craniectomy technique in two patients and the flip-over bull's-eye technique in one patient. The literature was reviewed on this entity and an algorithm based on the timing of presentation, extent of calcification and type of calcified cephalohematoma is proposed. Aspiration and compressive dressings can be used for early, incompletely calcified cephalohematomas. Calcified cephalohematoma causing significant distortion of the calvarium requires surgical correction and is classified as Types 1 or 2 depending on the contour of the inner lamella. Type 1, with a normal contoured inner lamella, can be corrected by ostectomy of the outer lamella. Type 2 calcified cephalohematoma has a depressed inner lamella. Elevation of the inner lamella is necessary and the cap radial craniectomy technique can be used. We describe a novel technique, the flip-over bull's-eye techniques as an alternative technique for Type 2 lesions in selected patients. In conclusion, calcified cephalohematomas can safely be treated surgically with excellent outcome. It is hoped that this algorithm will serve as a useful and logical guide in decision making for the management of this condition.