Early management of craniocerebral injury with avoidance of post-traumatic leptomeningeal cyst formation. Report of two cases

Treatment of a traumatic leptomeningeal cyst in an adult with fibrinogen-based collagen

Reports of traumatic leptomeningeal cysts (TLMC) are rare in adults. The standard treatment approach is craniectomy with careful exposure of the intact dural edges, followed by duroplasty. However, occasionally, the location of the TLMC makes achieving watertight duroplasty impossible. Herein, we report the case of a 28-year-old male who presented with a soft growing mass on the vertex of his head 16 months after the head trauma. Upon enhanced CT examination, a bony defect involving both the inner and outer table of the cranium was observed close to the sagittal sinus, and a well-defined cystic mass, 5 cm in diameter, was nested within the defect. The risks associated with extension craniotomy were high because the lesion was located superficial to the sagittal sinus, we opted to use fibrinogen-based collagen fleece (TachoCombR®) to repair the dural defect. Two months after surgery, the patient remained asymptomatic with a good cosmetic result. In cases like ours, when the defect is near the major sinuses and the risk of rupturing the sinus during watertight dural closure is high, fibrinogen-based collagen fleece (TachoComb®) is an effective alternative approach to standard dural suture techniques.

Prevention of growing skull fractures: report of 2 cases

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.

Adult traumatic leptomeningeal cyst: case report

A 60-year-old man presented with a traumatic leptomeningeal cyst manifesting as local tenderness in the right parietal region and local headache 2 years after head injury. Magnetic resonance imaging showed a small arachnoid cyst under bone defect. Dural and bone plasty were performed. Intraoperative examination found small and round defects of the dura and bone. Progressive headache was relieved after the surgery. This rare case of adult posttraumatic leptomeningeal cyst occurred within an unusually short period after trauma, and was associated with a small and round bone defect and small dural defect usually characteristic of congenital arachnoid cyst.

Leptomeningeal cyst due to vacuum extraction delivery in a twin infant

A rare case of a leptomeningeal cyst is reported in a twin male neonate delivered using a vacuum extractor, who presented a huge, non-pulsating, oedematous mass overlying the frontal fontanelle after birth. The mass was initially diagnosed as a cephalo haematoma. Ultrasonography indicated intracranial bleeding and a subsequent CT scan revealed an intraparenchymal bleeding above the left frontal horn, combined with a thin, left-sided, subdural haematoma and subarachnoid haemorrhage in the left Sylvian fissure. Apart from a bulging soft and round formation (2 x 2 x 3 cm) next to the anterior fontanel growing since birth, the neurological development of the infant was normal. MRI examination at the age of 7 months revealed that it consisted of a cystic mass (leptomeningeal cyst) connected to the left frontal horn, stretching right through the brain and also penetrating the dura mater. No signs of the perinatal haematomas were observed at this time. Surgical treatment, with fenestration of the cyst into the frontal horn and a watertight duraplasty with a periosteal flap and thrombin glue covered by small bone chips, was performed at 9 months of age. Due to a residual skull bone defect a second cranioplasty with autologous skull bone was performed three and half years later. During a follow-up period of 12 years the neurological and psychological development of the boy has been indistinguishable to that of his twin brother, indicating the satisfactory outcome of the treatment.

Growing skull fractures

INTRODUCTION

Growing skull fractures are a rare complication of head injuries (Ersahin et al. in Neurosurg Rev 23:139-144, 2000; Hayashi et al. in Childs Nerv Syst 13:349-351, 1997; Ramamurthi and Kalyanaraman in Neurosurgery 32:427-430, 1970; Zegers et al. in Eur J Pediatr 162:556-557, 2003). Although early diagnosis and prompt treatment are important to prevent the underlying progressive brain damage, the clinical presentation and the morphological investigations are rarely specific or sensitive shortly after the trauma.

DISCUSSION

The authors present three cases of growing skull fractures: the use of ultrasonography (US) via the fracture line contributed to early diagnosis and prompt treatment in two cases. US was not performed in the third case, and this delayed management. Treatment consisted of a watertight duraplasty with a free flap of pericranium without cranioplasty. US via the fracture line appears to be a sensitive and reliable method of detecting the dural tears in the early stages of growing skull fractures.

CONCLUSION

Duraplasty alone with a flap of pericranium remains the simplest and least expensive method of treatment. Cranioplasty is not necessary in young children.

Leptomeningeal Cyst Development after Endoscopic Craniosynostosis Repair: Case Report

OBJECTIVE AND IMPORTANCE:

Endoscopically assisted (minimally invasive) craniosynostosis repair has been suggested as an alternative to traditional open craniosynostosis repair. Advocates of this approach assert advantages, including decreased blood loss, operative time, and hospital stay, while providing esthetic results and safety comparable with traditional open craniosynostosis repair. The difficulties inherent in endoscopic visualization may result in complications, however, that could temper enthusiasm for this procedure. The authors report a child in whom a leptomeningeal cyst developed after performance of endoscopic craniosynostosis repair, presumably from an iatrogenic dural laceration.

CLINICAL PRESENTATION:

A 5-month-old girl with sagittal synostosis underwent endoscopically assisted craniosynostosis repair. By report, the procedure was uneventful and the initial results were acceptable. The authors performed a chart review of their own experience with both endoscopically assisted craniosynostosis repair and traditional open repair.

INTERVENTION:

Five months after surgery, a pulsating forehead mass developed. Neuroimaging confirmed the diagnosis of a leptomeningeal cyst. The child was referred to our pediatric neurosurgery practice for operative repair. At the time of surgery, a dural defect lying directly under a previous osteotomy site was identified. After uneventful repair and follow-up of more than 1 year, the child is well and is without the development of a clinical seizure disorder or recurrence of her leptomeningeal cyst.

CONCLUSION:

Unrecognized dural injury combined with an overlying osteotomy in an infant can result in the development of a leptomeningeal cyst. Care must be taken at the time of endoscopic extradural surgery to recognize any inadvertent dural tears and to perform a direct repair at the time of the initial occurrence. Facility with and use of an appropriate endoscope is essential to the safe performance of minimally invasive craniosynostosis surgery.