Midline depressed skull fracture presenting with quadriplegia: A rare phenomenon

Depressed skull fracture compressing eloquent cortex causing focal neurologic deficits

BACKGROUND

Depressed skull fractures are typically the consequence of high-impact injuries with inward buckling of the cranium. The majority of depressed skull fractures are managed conservatively in the absence of dural violation, sinus involvement, significant underlying hematoma, depressed fragment greater than 1 cm, wound infection, or gross wound contamination. Even in the presence of any of the aforementioned criteria, cranioplasty is typically considered an urgent procedure rather than a neurosurgical emergency. Rarely, a depressed fracture fragment can cause focal neurologic deficit(s) due to direct compression of the underlying eloquent cortex.

CASE DESCRIPTION

A 40-year-old male presented to the emergency department after a mechanical fall with a left central facial nerve palsy, left hemiplegia, left hemianesthesia, and fixed right gaze deviation. The neurologic deficits observed were attributed to a combination of blunt force trauma to the head (i.e., coup-contrecoup injury) and the depressed fracture fragment compressing the underlying eloquent cortex. He underwent emergent cranioplasty with fragment elevation within 2 hours of the traumatic injury. At 6-month follow-up, he regained full neurologic function without any residual deficits.

CONCLUSIONS

Our experience highlights a rare indication for emergent cranioplasty with an excellent functional outcome attributable to immediate fracture elevation and decompression of eloquent cortex.

A brief review of dural venous sinus injury with a short case series

Background

Dural venous sinus injury results in torrential hemorrhage and exsanguination. The initial review by Harvey Cushing had shown high mortality. The depressed fractures over sinuses were managed conservatively, because of the risk of massive hemorrhage during elevation. The consequences of sinus injury are hemorrhage, intracranial hypertension, brain swelling and venous infarct. Topical hemostatic agents such as gelatin sponge, oxidized cellulose, hemostatic matrix, bioresorbable plate, tissue-glue-coated collagen sponge, and fibrin glue help in controlling bleeding during surgery. The aim of the study is to analyze five cases of traumatic dural venous sinus injury. The literature review was done from Pubmed, Scopus and Google Scholar. A retrospective and descriptive analysis is done.

Case presentation

Among the five cases described, four had injury to superior sagittal sinus and one had injury to the transverse sinus. Two patients had open wounds. Three patients had continuous bleeding and two had intracranial hypertension. Decompressive craniectomy was done in three patients, wound hemostasis and closure in one, and craniotomy and evacuation of hematoma in one. Compression with Gelfoam was the main method for hemostasis and thrombin–gelatin hemostatic matrix had to be applied in two patients, with continued pressure for one hour.

Conclusions

Injury to the dural venous sinus should be suspected in fracture over the venous sinus. Surgery is indicated in active bleeding, expanding hematoma, compression or occlusion of the sinus and intracranial hypertension. Topical hemostatic agents help in controlling the bleed. Morbidity and mortality are more with involvement of middle and posterior third of superior sagittal sinus.