Consequences of dural defects acquired in infancy

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.

Intradiploic Encephalocele at the Parietal Bone: A Case Report and Literature Review

Intradiploic encephalocele is a rare condition of herniation of the brain parenchyma through the diploic space. A 52-year-old man presented with a parietal intradiploic encephalocele manifesting as an intermittent headache for 7 months. CT revealed an osteolytic lesion involving the right parietal bone. MRI demonstrated brain herniation within the diploic space. Surgery may be unnecessary in the absence of concurrent symptoms or neurological deficits. After 2 years of follow-up, symptoms were improved without neurological deficits and CT findings. We report the X-ray, CT, and MRI findings of an extremely rare case of parietal intradiploic encephalocele in adulthood.

Outcomes of Surgical Management of Metopic Synostosis : A Retrospective Study of 18 Cases

Objective

To describe the surgical management and postoperative outcomes in infants with metopic synostosis.

Methods

We conducted a 5 years retrospective chart review of patients who underwent surgical correction of metopic synostosis at two university hospitals in Egypt during the period between June 2014 and June 2019. The study is conducted to 18 children. The type of surgical procedures and postoperative outcomes were assessed in all patients.

Results

Five cases (27.8%) underwent endoscopic-assisted suturectomy, 10 cases (55.6%) underwent craniofacial reconstruction, and three cases (16.6%) underwent open burring of the metopic ridge. Fifteen patients underwent one surgery and three patients (16.6%) who need second operation. Ten patients (55.6%) had class I Whitaker classification.

Conclusion

Regardless of type of surgery, the outcomes of surgical correction of metopic synostosis are excellent with only a few patients require revision or develop major complications.

Growing skull fractures of the orbital roof: a multicentric experience with 28 patients

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.

Growing Skull Fracture: Case Report after Rottweiler Bite and Review of the Literature

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.

Surgical results of growing skull fractures in children: a single centre study of 43 cases

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.

Growing skull fractures after craniosynostosis repair: risk factors and treatment algorithm

Growing skull fractures (GSFs) are rare complications after severe head injuries in the early childhood and rarely occur after craniosynostosis repair. The aim of this study was to define an algorithm for sufficient treatment for GSF after craniofacial procedures. Literature research was performed to clarify risk factors for GSFs after cranial vault reshaping. Conclusions of the literature and experiences of the authors based on a case of GSF after craniofacial surgery were matched to establish guidelines for successful therapy.

Encéphalocèle intra-diploïque de l’adulte

We describe a rare case of parietal intradiploic encephalocele in a 51-year-old woman with no history of head trauma. The patient presented with a 1-month history of left hemiparesthesia. A hard indolent scalp lesion was palpable on examination in the right parietal area. Skull x-rays and cranial computed tomography examination demonstrated a lytic lesion that was consistent with a malignant osteolytic skull lesion. Magnetic resonance imaging of the head revealed an intradiploic cyst that included a round tissue mass contiguous with the parietal cortex. Surgery confirmed the diagnosis of encephalocele and the patient underwent surgical resection of the herniated brain, duraplasty, and cranioplasty. The presenting hemiparesthesia persisted at the 6-month follow-up. Encephaloceles of the cranial vault are a rare complication of skull fractures and rarely occur in adults. These lesions can be difficult to distinguish from congenital encephaloceles in patients with no history of head trauma. The pathogenesis, clinical and radiological nuances and the role of surgery are discussed.

Growing skull fracture: a posttraumatic neosuture

CONTEXT

A case of a growing skull fracture presenting in adulthood is reported. Pertinent literature was reviewed with an emphasis on pathogenesis.

EVIDENCE ACQUISITION

A search through MEDLINE from 1994 through 2004 was used and supplemented by searches of secondary sources retrieved from referenced articles.

EVIDENCE SYNTHESIS

Current hypotheses for the pathogenesis of growing skull fractures were critically analyzed. A new hypothesis based in more recent data is proposed in an attempt to better understand this process.

CONCLUSIONS

The proposed hypothesis seems to explain better the timing in which the clinical features in growing skull fracture develop.

Traumatic leptomeningeal cyst in a 24-year-old man: case report

OBJECTIVE AND IMPORTANCE

Traumatic leptomeningeal cysts represent a rare complication of a childhood cranial fracture, and occur in only 0.05 to 0.6% of all cranial fractures. In adults, clinical manifestations of a childhood trauma are very rare and usually appear in the form of nontender, nonpulsatile, subcutaneous mass, accompanied by a progressive neurological deficit and seizures, as shown in our case.

CLINICAL PRESENTATION

We present the case of a 24-year-old man with seizures caused by a traumatic leptomeningeal cyst resulting from the head injury he suffered at the age of 9 months.

INTERVENTION

Right-sided craniotomy was performed with consequent microsurgical removal of the leptomeningeal cyst. The dura was reconstructed in a watertight manner and a cranioplasty was performed with Palacos (Howmedica International, Limerick, Ireland).

CONCLUSION

It is important to consider traumatic leptomeningeal cysts when treating adult patients with erosive bone lesions who have a history of head trauma.

Complete osseous regeneration of a large skull defect in a patient with cutis aplasia: a conservative approach

Cutis aplasia (or aplasia cutis congenita) is a congenital absence of all skin layers, often extending through bone. This defect usually occurs in the scalp and can be extensive, exposing the dura mater, and deeper meninges. Treatment regimens for cutis aplasia have included early operative intervention, including skin and bone grafts, local scalp flaps, or free flaps to close the defect. In addition to the significant perioperative risks, these invasive procedures may inhibit the osteogenic potential of the dura to initiate and sustain bony closure of the defect. We report a case of an infant with Adams-Oliver syndrome and cutis aplasia involving a large portion of the skull that was treated conservatively with topical Silvadene dressings. No surgical treatment of bone or soft tissue reconstruction was necessary. This case report is the first to our knowledge to document complete bony restoration of the cranial vault through serial three-dimensional CT scans. The intensive therapeutic intervention in this case report allowed early discharge from the hospital, a gradual amelioration of the patient's alopecia as the hair-bearing scalp slowly covered the defect, and precluded the need for any subsequent bony reconstruction of the cranial vault. We hypothesize that conservative treatment of cutis aplasia maintains dural induction of osseous regeneration, and any treatment plan for bony defects of cutis aplasia should consider maintenance of dural integrity. Although further investigation is warranted, an initial trial of antimicrobial dressing care might optimally promote secondary closure of the cranial vault without the need for surgical intervention.

Post-traumatic intradiploic leptomeningeal fistula and cyst

A 59 year old female patient presented with ataxia and difficulty in walking. The neurological examination revealed right homonymous hemianopia and ataxia. Radiographic evaluation revealed a large occipital intradiploic cyst mainly in the left suboccipital area. There was also moderate hydrocephalus and encephalomalacia of the left occipital pole. Bone window studies also demonstrated a growing fracture extending from the upper pole of the cyst to the vertex. Both pathologies were attributed to child abuse the patient suffered when she was a child. At first surgery, decompression of the cerebellum was followed by duroplasty and acrylic cranioplasty to the posterior cranial fossa. A month later, a shunt had to be inserted for hydrocephalus. At 7 months postoperatively, the patient is well and free of any symptoms or recurrence.

Growing traumatic leptomeningeal cyst of the roof of the orbit presenting with unilateral exophthalmos

BACKGROUND

Growing skull fractures rarely develop in the skull base region. To the best of our knowledge, only two similar cases have been reported in the English literature. This rare complication, which can occur even after a mild head injury, can produce exophthalmos and threaten the vision.

METHODS

The clinical and radiological findings of expanding leptomeningeal cysts extending into the orbit in nine patients referred to the department of Neurosurgery are presented. After appropriate investigations confirming the presence of the expansile retroglobal lesion, surgical exploration was performed via fronto-lateral or the preferred fronto-basal approach. The variable findings are denoted and the relevant literature is also reviewed.

RESULTS

Frontobasal head injuries play an important role in pathogenesis of these traumatic expansile leptomeningeal cysts. In this series of nine young girls, 6.65% (six out of nine) injuries happened in the first decade of life with an interval of 2 to 12 months (mean = 6.7, SD = 9.7). High-resolution coronal view computed tomography (CT) scanning with bone density window images, and high intensity cystic lesions visible on T2-weighted coronal MR images were diagnostic clues.

CONCLUSIONS

Growing fractures of the anterior skull base may complicate the natural course of healing of any minor frontobasal head injury, especially during childhood. Good quality imaging is mandatory in cases of progressive unilateral exophthalmos. Proper surgical intervention will lead to a good cosmetic result.

Biodegradable semirigid plate and miniscrew fixation compared with rigid titanium fixation in experimental calvarial osteotomy

OBJECT

To determine the biocompatibility and suitability of resorbable plates and miniscrews, consolidation of symmetrical, bilateral frontal bone craniotomies that had been closed using various methods was studied in 20 growing lambs.

METHODS

Bone fixation with a flexible, punched polylactide plate and four slowly degradable, self-reinforced poly-levolactide (SR-PLLA) or rapidly degradable, self-reinforced polyglycolide (SR-PGA) miniscrews (10 animals in each group) was compared intraindividually with rigid fixation by using a titanium miniplate and four miniscrews. Plain x-ray films, magnetic resonance images, histological studies, and histomorphometric studies were obtained at 4 to 104 weeks.

CONCLUSIONS

No dislocation, instability, clinical foreign body reactions, infections, or loss of fixation were observed. Bone consolidation of the 2.35-mm-wide craniotomy lines was incomplete; connective tissue-filled defects through the bone were observed in 13 of 28 lines at 26 to 52 weeks. Statistical analyses based on histomorphometric studies showed no difference in consolidation with SR-PLLA miniscrew and titanium plate/screw fixation or between the two resorbable fixation methods. Fixation with rapidly degradable SR-PGA miniscrews resulted in less effective consolidation than on the contralateral titanium-treated side (p<0.05), but the bone segment was thicker (p<0.005). The SR-PGA miniscrews had disappeared by 6 weeks, the polyactide plate by 104 weeks, and the SR-PLLA miniscrews had been mostly resorbed at 104 weeks. Passive translocation of the titanium plates and screws into the bone tissue was seen at 52 and 104 weeks. In rapidly growing lamb frontal bone, comparable consolidation results, without complications, can be achieved with semi-rigid resorbable fixation compared with rigid metallic fixation.

Intradiploic arachnoid cyst with extensive deformation of craniofacial osseous structures: case report

OBJECTIVE AND IMPORTANCE

A unique case of a large intradiploic arachnoid cyst involving craniofacial osseous structures is reported.

CLINICAL PRESENTATION

The patient presented with a hard mass in the right frontal region, proptosis, and inferior globe displacement. Computed tomography revealed an intraosseous cyst of cerebrospinal fluid intensity with extension from the anterior cranial fossa to the infratemporal fossa.

INTERVENTION

After resection of the cyst wall and closure of two small round dural defects, the involved craniofacial region was reconstructed.

CONCLUSION

The medical history of the patient and the intraoperative observations support the contention that the cyst in the reported case was congenital in origin. The features concerned with diagnosis and pathogenesis of this rare entity are discussed.

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.

Consolidation of craniotomy lines after resorbable polylactide and titanium plating: a comparative experimental study in sheep

The consolidation process of craniotomy lines in a skeletally immature large mammal was studied. A traditional narrow titanium miniplate was compared with a 0.5-mm-thick, 12-mm-wide absorbable punched self-reinforced poly-L-lactide (SR-PLLA) plate, both fixed with titanium miniscrews over bilateral parietal 2.5-mm-wide stable transosseous craniotomies on nine female sheep (16 to 20 months old). After 6, 12, 20, 52, and 104 weeks, cross-sectional histology, histomorphometry, and oxytetracycline chloride fluorescence studies were done to compare the healing process of the craniotomy lines and to study the biocompatibility and the degradation process of the SR-PLLA plate. The consolidation pattern supported the principle of guided tissue regeneration: under the wide, resorbable plate osseous bridging proceeded evenly throughout the line, whereas titanium plating led to bulky, uneven growth in the bone margins. All SR-PLLA-plated osteotomy lines had healed completely by 20 weeks, whereas none of the titanium-plated lines had consolidated during a follow-up of 1 year. The nonossified gaps were filled with dense connective tissue. Histomorphometric analysis showed that osseous bridging proceeded significantly faster on the resorbable plate side compared with the titanium side (p < 0.001). The osteoid surface fraction over the total trabecular surface was highest at 6 weeks, being 63 percent on the SR-PLLA side and only 36 percent on the titanium side. The oxytetracycline chloride fluorescence studies confirmed these findings. After 52 weeks, there was no osteoid or oxytetracycline chloride fluorescence left as a sign of terminated ossification, even in the nonconsolidated titanium sides. Microscopic cracking of the plate was evident at 12 to 20 weeks, and the first signs of active resorption were present at 52 weeks. After 2 years, the plate had disappeared and tiny polylactide particles were being actively reabsorbed. The biocompatibility of SR-PLLA and titanium was good, and no adverse cellular reactions to these materials were noted, except a clinical foreign body reaction caused by loosened titanium miniscrews. A densely punched, 0.5-mm-thick self-reinforced PLLA plate seems to retain its integrity for a sufficiently long time to complete osseous healing of a 2.5-mm-wide craniotomy line in the sheep calvarial area. A thin, wide fixation plate enables superior healing, especially in osseous defects. The degradation process of the SR-PLLA plate begins within 1 year and is far advanced after 2 years. By using absorbable SR-PLLA fixation plates instead of metallic plates, a subsequent operation for the removal of the implants can be avoided. SR-PLLA devices could thus be a potential additive or even alternative to metallic implants in craniofacial surgery.

Growing skull fractures: a clinical study of 41 patients

Growing skull fractures are rare complications of head injury, occurring almost exclusively in infants and children under the age of three. A retrospective review at our Institute yielded 41 patients with this entity over a period of 20 years (1975-1995). The age at presentation ranged from less than 1 year to 62 years, with 33 (80.5%) patients being less than 5 years of age. The cause of injury was either a fall from a height (93%) or a road traffic accident. The most common location of a growing skull fracture was either parietal or frontoparietal (56%). One patient had a posterior fossa growing skull fracture. CT scan was performed in 19 patients which demonstrated an underlying porencephalic cyst, hydrocephalus or a cyst communicating with the ventricle. In 5 children, a ventriculo-peritoneal shunt alone was performed. Twenty four patients underwent a duro- and cranioplasty while a duroplasty alone was performed in 8 patients. The material used for cranioplasty included acrylic, wire mesh, steel plates or autologous bone. Three patients died, one due to an anaesthetic complication and two as a result of postoperative meningitis. Post-operative CSF leaks occurred in 3 patients, which were managed by a lumbar drain. Six patients had local wound infection.

Iatrogenic intradiploic meningoencephalocele. Case report

The authors present the case of a 6-year-old girl who developed a right frontal intradiploic meningoencephalocele following an accidental dural tear produced during surgery for craniosynostosis. Although rare, growing skull fractures have been described in at least eight cases following the accidental laceration of the dura mater in the course of craniosynostosis repair. These cases closely resemble those produced by accidental trauma to the growing skull. However, the intradiploic location of a meningoencephalocele following surgery for craniosynostosis has not been documented previously. This patient presented with headache and a frontal tumor of bonelike consistency. Radiographs and computerized tomography scans of the skull revealed an intraosseous cyst, whereas magnetic resonance imaging demonstrated cerebral tissue herniation within the intradiploic tumor. Surgical treatment consisted of duraplasty and cranioplasty, which achieved good functional and cosmetic results. The pathogenesis of this unusual lesion is discussed and compared with the hypotheses advanced for explaining posttraumatic intradiploic cysts.

Growing fracture of the orbital roof

BACKGROUND

Growing fractures rarely arise in the skull base, and their pathogenesis and treatment are still debated.

METHODS

The clinical and radiologic findings of a growing fracture involving the orbital roof in a 5-year-old boy are presented and the relevant literature is reviewed.

RESULTS

The clinical picture of growing fracture of the orbital roof is dominated by ocular symptoms such as diplopia, eyelid swelling, and displaced eye globe. Computed tomography scan is excellent for demonstrating the bony defect in the orbital roof while magnetic resonance imaging is more sensitive in showing the intraorbital extension of the leptomeningeal cyst. Frontobasal brain injury seems to play an important role in the pathogenesis of the fracture growth. Craniotomy with direct repair of the dural and bone defects is the treatment of choice.

CONCLUSION

Growing fracture of the orbital roof may complicate minor head injury and should be considered in the differentiated diagnosis in cases of persistent ocular symptoms.

Cranial burst fracture in infants: acute recognition and management

In the past, the diagnosis of "growing skull fracture" or "diastatic fracture" has included a subset of injuries better referred to as "cranial burst fracture." Cranial burst fracture, typically associated with severe injury in infants less than 1 year of age, is a closed, widely diastatic skull fracture accompanied by acute cerebral extrusion outside the calvarium. We treated 11 such infants at the LeBonheur Children's Medical Center and 2 at the Children's National Medical Center from January 1986 through December 1994. Infants ranged in age from 1 to 17 months, with an average age of 5.7 months. All presented with marked scalp swelling and a Glasgow Coma Scale score of 10 or less. Twelve had a history consistent with severe injury (motor vehicle accident, 7, abuse 5). The cause of injury in one patient remains unproven. Surgery (reduction of herniated cerebral tissue, repair of large dural laceration, and cranioplasty) was usually performed within 10 days of injury, a time period long enough to assure hemodynamic stability and resolution of acute cerebral swelling, yet sufficiently brief to avoid the chronic changes (scarring, parasitization of scalp vessels by damaged cortex) associated with a "growing skull fracture." Prompt repair of cranial burst fracture may prevent ongoing brain injury such as has been neuropathologically demonstrated in patients with "growing skull fracture." Magnetic resonance imaging establishes the diagnosis of cranial burst fracture in equivocal cases, rendering unnecessary a "waiting period" to see if scalp swelling resolves. Our experience, together with information in the neuropathological and neurosurgical literature, suggests that cranial burst fracture is associated with severe trauma, requires expeditious treatment, and has been underdiagnosed in the past, leading to "growing skull fracture," a condition requiring more extensive surgery.

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 childhood. A recurrent case treated by shunt operation

The authors report a case of growing skull fracture in which watertight dural closure was difficult at the first operation because a dural defect extended deep into the middle fossa. Bulging of the cranioplasty site occurred 2 months later. In the second operation, instead of reinforcement of the dura mater, a shunt operation was performed to decompress the cyst and the locally dilated ventricle, which was thought to contribute to the intracranial expansive forces. The bulging did not recur. In the treatment of growing skull fracture, a shunt operation should be considered when watertight closure of the dural defect cannot be achieved and in case of recurrence after failure of the first operation.