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Seven patients with growing skull fractures treated between 1983 and 1993 are described. These growing fractures constituted 1.6% of all the cases of skull fractures seen during the period (a total of 449 cases). Based on aetiopathogenesis, computed tomography (CT) appearances, operative findings and management strategies required, three main types...
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... neurological deficit; 7 as was seen in most of our cases. Because of the diverse clinical, radiological (CT) and operat- ive findings and variable temporal course, there is controversy concerning the terminol- ogy, aetiopathogenesis and management of growing skull fractures. 3 ' 6,8 Classification of the growing skull fractures into three types ( Fig. 1) suggested here was found to be help- ful in explaining these diversities and planning the treatment. Similarly, based on the clinical presentation and temporal course, two forms of the growing skull fractures could be dis- tinguished. An active form with evidence of raised intracranial pressure (ICP), mass effect on CT, progressive ...
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... of the pupils to the light was very sluggish but equal. Visual evoked potentials (VEP) confirmed cortical blindness. Plain radiography of the skull on this second admission showed a large, occipital bony defect with scalloped margins (Fig. 9). CT at this stage showed resorption of a portion of the occipital bone and underlying brain lesions (Fig. 10). At surgery, the CSF- containing occipital cyst was aspirated and an acrylic cranio plasty carried out. This child was re-admitted 2 months later, this time with a collection of fluid under the acrylic cranio- plasty. A further operation was carried out. A water-tight repair of the dural defect was achieved using a pericranial graft ...
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... 6. This child was hospitalized for 3 days for head injury at the age of 5 months. Skull radiography and CT showed a left parieto-oc- cipital fissured fracture of skull with minimal underlying contusion (Fig. 11). Nine months later she presented with a large skull defect and tense scalp swelling at the site of the fracture, along with increasingly frequent seizures and delayed speech. Radiography now showed a large, gaping skull defect at the site of original fracture (Fig. 12) and CT showed the gaping fracture with hypodensity of the ...
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... cipital fissured fracture of skull with minimal underlying contusion (Fig. 11). Nine months later she presented with a large skull defect and tense scalp swelling at the site of the fracture, along with increasingly frequent seizures and delayed speech. Radiography now showed a large, gaping skull defect at the site of original fracture (Fig. 12) and CT showed the gaping fracture with hypodensity of the underlying brain and dilatation of the ipsilat- eral ventricle (Fig. 13). Surgery was refused in spite of progressive neurological and radiologi- cal ...
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... skull defect and tense scalp swelling at the site of the fracture, along with increasingly frequent seizures and delayed speech. Radiography now showed a large, gaping skull defect at the site of original fracture (Fig. 12) and CT showed the gaping fracture with hypodensity of the underlying brain and dilatation of the ipsilat- eral ventricle (Fig. 13). Surgery was refused in spite of progressive neurological and radiologi- cal ...
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... 7. A 39-year-old woman was seen for increasing right-sided head pain. At the age of 18 years she had suffered a head injury in a car accident. On examination, a large gaping skull defect was present in the right parietal region. Skull radiography showed a widely gaping right parietal defect (Fig. 14), CT showed the skull defect and underlying leptomeningeal cyst (Fig. 15). Durocranioplasty was straight- forward, and resulted in resolution of head- ache and closure of the skull defect. ...
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... woman was seen for increasing right-sided head pain. At the age of 18 years she had suffered a head injury in a car accident. On examination, a large gaping skull defect was present in the right parietal region. Skull radiography showed a widely gaping right parietal defect (Fig. 14), CT showed the skull defect and underlying leptomeningeal cyst (Fig. 15). Durocranioplasty was straight- forward, and resulted in resolution of head- ache and closure of the skull defect. ...
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... all the seven patients had skull radiographs which showed linear fractures. The initial head injury was not considered serious enough to warrant CT in the first instance, except in cases 5 and 6 where CT at the time of trauma confirmed the fissured skull fractures without evidence of significant contusions or damage to the under- lying brain (Figs. 8 and 11). Delayed CT showed the fracture growth (Figs. 10 and 13) and, more importantly, appearance of exten- sive fresh lesions with marked and possibly continuing damage to the underlying brain (Figs. 10 and 13). CT correctly demonstrated the nature and extent of the intracranial path- ology including areas of cephalomalacia, sub- dural, ...
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... showed linear fractures. The initial head injury was not considered serious enough to warrant CT in the first instance, except in cases 5 and 6 where CT at the time of trauma confirmed the fissured skull fractures without evidence of significant contusions or damage to the under- lying brain (Figs. 8 and 11). Delayed CT showed the fracture growth (Figs. 10 and 13) and, more importantly, appearance of exten- sive fresh lesions with marked and possibly continuing damage to the underlying brain (Figs. 10 and 13). CT correctly demonstrated the nature and extent of the intracranial path- ology including areas of cephalomalacia, sub- dural, leptomeningeal and porencephalic cysts, as well as ...
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... CT at the time of trauma confirmed the fissured skull fractures without evidence of significant contusions or damage to the under- lying brain (Figs. 8 and 11). Delayed CT showed the fracture growth (Figs. 10 and 13) and, more importantly, appearance of exten- sive fresh lesions with marked and possibly continuing damage to the underlying brain (Figs. 10 and 13). CT correctly demonstrated the nature and extent of the intracranial path- ology including areas of cephalomalacia, sub- dural, leptomeningeal and porencephalic cysts, as well as ventricular dilatation (com- plete or only one ...
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Background:
Negative-pressure hydrocephalus is a rare condition with the development of symptomatic hydrocephalus despite subnormal intracranial pressure (ICP). The etiology remains unclear. Some authors proposed that the differential pressure between the ventricular space and the subarachnoid space over cerebral convexity leads to the development...
Citations
... Type III is the unusual pattern in which porencephalic cyst communicating with ventricular system is herniated through the bony calvarium. [7] CT carried out before the development of leptomeningeal cyst delineates the fracture pattern and associated haemorrhagic contusions. Widening of fracture line, everted edges of fracture and herniation of intracranial contents are the signs of leptomeningeal cyst formation on CT imaging. ...
Background
Growing skull fracture or leptomeningeal cyst is an uncommon occurrence after severe head trauma in childhood. It is mostly observed in infants and children less than 3 years of age. Another uncommon complication of head trauma is development of porencephalic cyst.
Case presentation
We present an unusual case of post-traumatic type III leptomeningeal cyst in a 9-month-old infant with history of head trauma 3 months ago. CT and MR imaging revealed widening of bony defect compared to previous imaging, and herniation of porencephalic cyst through the defect, leading to formation of a large cystic swelling in scalp. The 3 month delay in evaluation of the scalp swelling was due to lack of patient education after trauma, and no subsequent follow-up.
Conclusions
Knowledge about etiopathogenesis and risk factors of leptomeningeal cyst development after head trauma ensures that close follow-up is done in such cases for early detection and management of growing skull fracture.
... A study on seven patients, based on CT, surgical findings, etiopathogenesis, and necessary therapeutic approaches, distinguished between three primary forms of GSFs: leptomeningeal cysts, in three patients; damaged and gliotic brain, in three patients; and porencephalic cysts extending through the skull defect into the subgaleal region, in two patients [11]. The first surgical step in treating this issue is a duraplasty, as we did in our case. ...
... In the case of a herniated gliotic parenchymal or leptomeningeal cyst, however, the surgical approach may involve the excision of both the tissue and the cyst. Cranioplasty should be done after duraplasty [11]. The mortality rate (due to anaesthesia and meningitis) ranges from 0% to 8%. ...
Pediatric growing skull fractures are complications that usually occur due to delays in management. In this report, we present the case of a three-year-old girl who was brought to the outpatient department with a complaint of swelling in her scalp. The patient had a history of swelling after suffering a head injury at the age of six months. There was no history of specific neurological impairments or seizures, despite the swelling being reported to have grown gradually in size. The current case is being reported since early evaluation of pediatric patients with a head injury, regardless of any neurological shortfalls, should be thoroughly worked up to prevent any progressively growing cranial defects. The subtlety of these pediatric head injury cases tends to cause misdiagnosis, which can delay management and can cause complications, as with this patient. Extended observation, intensive supportive care, and neurosurgery are considered when dealing with these seemingly innocuous cases.
... The treatment of GSF involves surgical repair of the dura mater tear and cranioplasty. In the treatment of GSF, surgery should be performed to prevent further brain damage, and the most important technique is watertight closure of the dura mater 23,31) , which includes removal of the leptomeningeal cyst and encephalomalacia. If the dural defect is wide, fascia lata, cadaveric dural grafts, and artificial dura are often used. ...
Traumatic brain injury (TBI) is a major public health issue that causes significant morbidity and mortality in the pediatric population. Pediatric minor TBIs are the most common and are widely underreported because not all patients seek medical attention. The specific management of these patients is distinct from that of adult patients because of the different physiologies in these age groups. This article focuses on minor TBIs, particularly growing skull fractures, traumatic cerebrospinal fluid leakage, and concussion.
... GSF are rare and their incidence has been estimated as 0.05% -1% of all pediatric skull fractures [1] [2]. This low incidence and the subtlety of its presentation often make diagnosis challenging with consequent delay in management [3] [4] [5] [6] [7]. CT scan or MRI is the imaging modality study to confirm the diagnosis. ...
... Type I is characterized by the presence of leptomeningeal cyst, whereas type II features the presence of gliotic brain. Type III is characterized by the existence of porencephalic cyst that extends through the skull defect into the subgaleal space [16]. ...
... The standard surgical treatment relies on duraplasty in all patients and or cranioplasty in some situations [16][17][18][19][20][21][22]. ...
... The mainstays of treatment in GSFs are duraplasty and cranioplasty [16,21,22,25]. Shunt operation may be performed in some cases with porencephaly [22]. ...
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.
... Few cases of LMC have been described in adults [3,4]. Usual clinical presentation is with pulsatile tense swelling, seizures, motor deficits, and developmental delays [5][6][7]. Clinical manifes-tation occurs within few weeks to months; 50% present within a year and 80% within the first 5 years after the initial trauma [5]. Unusual presentations include delayed presentations even upto 25 years after trauma, CSF fistulas with recurrent meningitis and tumour mimic [3,4,8,9]. ...
... GSF is a spectrum having different grades of severity with different contents herniating through the bone and dural defect. Naim-ur-Rahman et al. [6] classified the GSF into 3 types based on these observations. The classification has implications in clinical features and treatment modality to choose from (Fig. 3). ...
... Very large LMC may additionally benefit from cysto-peritoneal shunt. When brain parenchyma is herniating through the dural tear (Naim type 2), it may require the excision of herniating gliotic brain [5,6]. Many authors do not favour resection of brain and advise electrophysiological monitoring if resection is planned as most of the GSF are in vicinity of motor cortex [11]. ...
Introduction:
The growing skull fracture (GSF) is a rare complication seen after head injury in infants and young children. It occurs due to a wide skull defect with underlying dural defect and changes in pressure gradients within skull cavity. Neglected cases may develop progressive neurological deficits and complications after second head trauma. Case Discussion: We present a 14-year-old child who developed sudden-onset, diffuse, soft, fluctuant, circumferential swelling of the head after a road traffic accident. He had sustained a head injury at the age of 3-months leading to an asymptomatic soft swelling over the skull which was left untreated. Present CT scan of the brain showed a bony defect with ragged edges and cerebrospinal fluid (CSF) collection in subgaleal space circumferentially. He underwent exploration, duroplasty, and cranioplasty and had a good outcome.
Conclusion:
Neglected GSF can rupture and cause diffuse subgaleal CSF collection. It should be managed with dural repair and cranioplasty.
... Growing skull fracture (GSF) is a rare type of pediatric skull fracture, with an incidence rate of <1%, and it commonly occurs in children aged below 3 years. 8,10,12) The mechanism of the GSFs is due to the herniation and enlargement of gliotic brain tissues through the site of dura tear. 1,7,12) Neurologic symptoms and signs of GSF may vary based on the site of injury and the hemiparesis can occur with the parietal predominance of GSF. ...
... GSF is a rare type of skull fracture that commonly occurs in children aged below 3 years and more than 50 percent of it occurs under 12 months. 8,10,12) The incidence of GSF is reported from 0.05% to 0.6% in pediatric skull fractures. 8,10,11) The condition is caused by falling, vehicular accident, and child abuse. ...
... 8,10,12) The incidence of GSF is reported from 0.05% to 0.6% in pediatric skull fractures. 8,10,11) The condition is caused by falling, vehicular accident, and child abuse. 4,10) It is accepted that the most important factors for https://kjnt.org ...
Growing skull fracture (GSF) is a rare complication of skull fracture in children. We report a case of GSF, also known as leptomeningeal cyst with significant damage in the motor cortex in a 50-day-old child, but the motor function was preserved. A 50-day-old male baby visited our hospital after trauma in the left side of the head. His level of consciousness and motor function were normal. Brain computed tomography (CT) scan revealed gapped skull fracture of the left parietal lobe with underlying contusion and subdural hemorrhage. During hospitalization, bulging in the left parietal scalp had progressed, and follow-up magnetic resonance imaging revealed increased skull defect with enlarged leptomeningeal cyst at the left motor cortex. Cranioplasty and duroplasty were performed. Intraoperatively, a dura tear, brain tissue herniation and fluid collection around the motor cortex were observed. One-year follow-up CT revealed cystic encephalomalacia in the left motor cortex. During the 30-month follow-up, nearly normal gross motor function was observed except for few fine motor impairments. We report a case of GSF with significant damage on the motor cortex in an early infant, but with the preserved motor function during the postoperative developmental process.
... Post-traumatic leptomeningeal cysts are an uncommon but well-recognized late complication of head injury in childhood, and are included in the larger "growing skull fracture" entourage [1,2]. Very few cases have been reported in adulthood, cerebrospinal fluid leakage and appearance of a lump being the most common complaints in this setting. ...
... Growing skull fracture (GSF) is a well-known but uncommon complication of pediatric head trauma, 1 with the reported incidence ranging from 0.05% to 1.60%. 2 It was first described in 1816, and its mechanism has been elucidated in several reports. [3][4][5][6][7][8] Four essential factors associated with the incidence of GSF have been reported: (a) skull fracture during infancy or early childhood, (b) dural tear with an intact arachnoid membrane at the time of fracture, (c) underlying parenchymal injury, and (d) cranial defect resulting from enlargement of the fracture gap. 4 Most GSF cases occur in children aged less than 3 years, of which almost 50% occur in those aged less than 1 year. 6,9 The dura is more easily torn at these susceptible ages because of its tight adhesion to the skull as well as the particular features of the skull in young children (i.e., thinner, less stiff, and more deformable than the skull in older children and adults). ...
... basis of this mechanism, GSF is mainly classified as the leptomeningeal cyst type, which forms through herniation of the arachnoid, or the brain evacuation type, which forms through herniation of brain tissue (Fig. 4a, b). 5,7,8 However, in the present case, GSF occurred only several weeks after the head injury, and the herniated region was not consistent with either of the two types. Instead, cerebrospinal fluid and brain tissue herniated into the intraperiosteal space, suggesting a different mechanism altogether (Fig. 4c). ...
Growing skull fractures (GSFs) are well-known but rare causes of pediatric head trauma. They generally occur several months after a head injury, and the main lesion is located under the periosteum. We herein report a case involving a 3-month-old boy with GSF that developed by a different mechanism than previously considered. It developed 18 days after the head injury. A large mass containing cerebrospinal fluid and brain tissue was present within the periosteum. A good outcome was obtained with early strategic surgery. Injury to the inner layer of the periosteum and sudden increase in intracranial pressure might be related to GSF in this case.
... Duraplasty is the main point (22,23). Dural tears with pulsation of CSF cause bone diastasis (4,19). ...
Growing skull fracture (GSF) is a rare complication of cranio-cerebral injuries in infants and children under three years of age. Falls and blunt force head trauma are the most frequent causes of head injuries. GSF usually results from a linear calvarial fracture, however, it may also occur due to a closed-head injury. The most common symptom is scalp swelling without progressive tenderness or pain. The most common site of GSF is the parietal region. GSF may cause epilepsy, neurologic disorders and calvarial asymmetry. Duraplasty in early period of GSF is recommended in order to have better results. Here, we report a 15-month-old girl with parietal bone fracture who was followed closely both clinically and radiologically and underwent surgical repair of GSF and enlargement of the dural defect. © 2018 by The Medical Bulletin of University of Health Sciences Haseki Training and Research Hospital The Medical Bulletin of Haseki published by Galenos Yayınevi.
