growing skull fractures classification and management

8/13/2019 Growing Skull Fractures Classification and Management

1/12

British Journal of Neurosurgery (1994) 8 , 667-679

ORIGINAL ARTICLE

Growing skull fractures: classification and management

N A I M - U R - R A H M A N , ZA I N A L A B E D E E N B . J A M J O O M , A B D E L H A K I M B .

J A M J O O M & W A L E E D R . M U R S H I D

Division of Neurosurgery, College of Medicine, King Saud University & King Khalid University

Hospital, P.O. Box 2925, Riyadh 11461, Saudi Arabia

Abstra c t

Seven patients with growing skull fractures treated between 1983 and 1993 are described. These growing

fractures consti tute d 1.6% of all the cases of skull fractures seen during the period (a total of 449 c ases) . Base d

on aetiopathogertesis, computed tomography (CT) appearances, operative findings and management strategies

requir ed, three main types of growin g skull fractures were reco gni sed. In type I (n 3) a lept omcn ingc al cyst, in

type II in = 3) damaged and gliotic brain, and in type III (n = 2) a porencephalic cyst extended through the skull

defect into the subgalcal sp ace. A combi nat ion of type I and type III co-e xist ed in one patient . Initial head injury

and neurolo gical deficit were judged to be mi ld to mod erat e in all the seven cases. C ont inu ed growth of skull

fractures correlated closely to the increasing neurological deficit in five cases. In two patients natural arrest of

fracture growth at 5 and 7 months after trauma was accompanied by arrest in progress of neurological deficit.

Available surgical options are discussed and general guidelines for the management are given.

Key wo rds : Trauma, lepzomeningeal cyst, porencephalic cyst, meningocele spuria, progressive neurological deficit, skull

fracture

Introduction

Linear or non-linear skull fractures in chil

dren that enlarge with t ime are termed grow

ing skull fractures.1

Although these lesions are

much more common in ch i ld ren ,2

and 90%

occ ur un de r the age of 3 years;3

the process

may occur following a skull fracture in an

a d u l t .2 , 4 , 5

The incidence of 'growth ' as a de

layed compl icat ion of skull fracture is rare and

occ urr ed in only 0. 6% of the cases in on e large

series ,6

It is important to realize that the lesion

expands not only between the frac ture edges ,

but also intracranially and, thus, may cause

atrophy of under lying cereb ra l t issue with re

sul t ing progress ive neurological defic i t ;7

as was

seen in mo st of our cases. Beca use of the

diverse clinical, radiolo gical (C T) an d ope rat

ive f indings and variable temporal course ,

there is controversy concerning the terminol

ogy, ae t iopathogenes is and management of

growing skul l frac tures .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

presenta t ion and temporal course , two formsof the gro wing skull fractur es could be di s

tinguished. An active form with evidence of

raised intracranial pressure (ICP), mass effect

on C T , progress ive separa t ion of bo ne edges

with a tense bulge between them; and an ar-

667


2/12

668 Naim-Ur-Rahman et al.

S e a r r t d a r a c h n o i d

TYPE m

FI G. 1. Th e three main types of the growing skull fractures.

rested or 'burnt out' form with a normal ICP,

and a slack/sunken gap between the bone

edges often showing som e evide nce of bon e

regrowth and healing at the fracture site.

Duro-cranioplasty was the correct treatment

for type I fractures without raised intracranial

pressure; whereas a shunting procedure was

required as an initial or definitive management

for type I and III fractures with raised intracra

nial pressure.

Report of cases

A su mm ar y of the seven patien ts is pres ent ed

in Table L and management options summa

rized in Table III .

Clinical Data

Six patients were children while one was 39

years old. In the paediatric group, the age at

the tim e of diagnosis rang ed from 4 mo nt hs to


3/12

Growing skull fractures 669

6 years (mea n: 24,6 mont hs) . Six pat ien ts

were female and one male. The interval be

twe en the history of he ad injury and diagn osis

of grow ing skull fracture ra nge d from 2

months to 1 year (mean: 7 months) . Locat ion

of the skull fracture was pariet al in th ree

pat ients , frontoparie ta l in one, occipi toparie ta l

in one, and occipital in the remaining two

children.

Two children (cases 1 and 2) had experi

enced permanent remiss ions af ter a period of

act ive frac ture growth. Th e rema inin g f ive

sho wed evide nce of raised intracr anial pres s

ure and more or less progressive neurological

deficits . Five children presented with swelling

in the re gion of th e fra ctur e site, whi le in two

(cases 1 an d 7), the area be tw een the gaping

bone edges was slack and depressed. Seizures

and hem ip a re sis were the next common

present ing symptoms and occurred in four

patients. Blindness or progressive visual

deterioration was present in two children with

occipital fractures, while retardation was seen

in one child.

Radiological evaluation

Plai n radio gra phs of the skull an d CT were

performed on a l l pa t ients . Skul l radiographs

correct ly demonstra ted the locat ion and extent

of separ ation of bo ny edges at the fra cture site.

Extens ive bony resorpt ion with widely gaping

everted fracture margins, seen in three chil

dre n, corr elated well with the size of the u n

derlying cyst and brain damage on a CT scan.

CT clearly demonstra ted the bony defect ,

the natu re of intracrania l cont ents hernia t ing

th ro ug h it (lepto meni ngea l cyst = 3, con tuse d

cereb ral tissue = 3, por enc eph ali c cyst -2);

and the extent of the underlying intracranial

les ion. Thus , a leptomeningeal cys t with CSF

density was seen in three patients, extensive

low density areas of bra in dam ag e an d en-

cephalomalacia in three pat ients and poren

cephal ic cys ts communicat ing with di la ted

ventricles in two children.

Operative findings

Five of the seven pat ien ts und er we nt surgery.

One child (case 4) had a ventriculopcritoneal

shunt for tense porencephalic cyst and dilated

ventricles. In the remaining four children the

defect was repaired by duroplasty using fascia

lata or pericranial graft, and an acrylic cranio-

plasty. Of these four chil dren who un der

went craniotomies at the fracture sites, two

(cases 2 and 4) showed that the scalp and

pericranium were densely adherent to the

underlying conges ted, gl iot ic and hernia ted

brain. The dura was totally absent under the

cranial defect. More or less extensive nibbling

of the ma rgi ns of bo ne defect was requi red to

find a reas ona ble dural e dge. D issect ion an d

elevation of the scalp flap from the unde rly ing

congested gliotic brain was tedious and ac

companied by much bleeding. In case 5, oper

ation was performed for a large tense occipital

swelling thr ou gh a growin g fracture of the

skull. Ele vat ion of a large occi pital scalp flap

revealed a porencephalic cyst on the right side

and a leptomeningeal cyst overlying a con

gested and softened left occipital lobe. The

occipital cyst was aspirated and an acrylic

cranioplas ty carr ied out . Durocranioplas ty was

straightforward in the seventh case.

Surgical results

Com ple te reso lut ion of the ra ised intracrania lpressure, extracranial swelling and progressive

closur e of skull defect was o bta ine d in the

child who underwent shunt surgery (case 3).

Fol low-up a t 3 and 6 months has shown re

du ct io n in th e size of cran ial defect with evi

den ce of bo ne regr owt h at the fract ure site.

Co mp le te obli tera tion of the crania l defect was

achiev ed in three ou t of four pat ien ts who

underwent duro-cranioplas ty (mean fol low-

up : 4 years ). In the fo urth pati ent, the acrylic

plate loosened and bulged 2 years after

surger y. Re ope rat ion was refused. All the five

pat ients who underwent surgery recoveredwithout any increase in the pre-exis t ing neuro

logical deficits and definite improvement was

recorded in four pat ients .

Case 1. This 30-monrh-old gir l was wel l unt i l

10 months before admiss ion when she was


4/12

TA BL L Summary of seven patients with growing skull fractures-Jo

Case

no. Age/sex*

Location of

fracture

Type &

temporal

classification Presentat ion and c'imca] examinat ion

Skull

radiography

C T

appearance Treatment Outcome

53

30 months

F

72 months

F

4 months

F

Parietal

Parietal

Occipital

15 mont hs Occipital

I

Arrested

(burnt-out)

II

Arrested

[|]

Active

36 mont hs Frontoparietal II

h" Active

I&III

Active

Slack depression in the region of

fracture^ improving left berra'paresis,

Retardation

Slack swelling right parietal region

seizures, minimal left hemiparesis

Tense, increasing bulge overlying

left occipital bone defect.

RICPj vomitings papi l ledema,

?Blindness

Tense swelling left forehead,

occasional headaches and vomiting,

seizures, Q progressive) right

hemiparesis

Tense enlarging swelling occipital

region, blindness, progressive

neurologic deficits

Gaping bone

defect with

everted margins

Gaping defect

right parietal

Large, wedge-

shape bone gap

with extensive

re^irprion

Atrophic (drained) right

parietal leptomeningeal

cysts with ipsila i:ral

pulling of midline

Low density, atrophic

cerebral tissue

underlyin g skull defect

I-argc left oceipital

porencephalic cyst

communicating with

the dilated lateral

ventricles and

herniating through the

occipitoparietal defect

Extensive gaping

fracture left

fronto-parietal

involving anterior gaping fracture

cranial fossa

Low density atrophic

cerebral tissue

herniating through

Gaping,

bioccipital

bony defects

Conservative

? Spontaneous cure

Duropla&ty and acrylic

craniopiasty

Cysto- ventricuiop eritoneal

shunt

Bilateral occipital

cephalomalacia? large

right occipital

porencephalic cyst

communicating with

dilated lateral

ventricles and

herniating through bone

defect + left

leptomeningeal cyst

Duroplasty and acrylic

craniopiasty

Acrylic craniopiasty

followed by

recurrence,

followed by repeat

duro-cranioplasty

Being followedjf

Evidence of

improving deficits

and bone regrowth

at fracture site

C u r e d !

Curedf

Recurrence!

after surgery

Improved!

Followed-up to 3

years has

defective vision

V.E.P. = poor

response =

cortical

blindness


5/12


TA BL E II. Management options

Growing skull fracture

With normal

1CP

With raised

1CP

Tense porencephalic

cyst with

hydrocephalus

Ventri c ulo peritoneal

shunt

I

I

I

I

Tense

leptomcningcal

cyst

Cysto-peritoneal

shunt

I

I

Duro-cranioplasry

tre ate d for he ad injur y with a frac ture of th e

skull. Over the next 5 months the child devel

ope d bulgin g of the scalp i n the right parieta l

region which became progressively larger.

This was accompanied by progressive left

hem ip ares is , headache, vomiting and oc

casional seizures. Five months prior to ad

miss ion the mother not iced a spontaneousimprovement in chi ld ' s condi t ion. The scalp

bulge became softer then rapidly disappeared

leaving a depressed gap between the bone

edges . This was accompanied by resolut ion of

headache and vomit ing, and improvement in

the left-sided weakness. The child was admit

ted to the neurosurgical unit with the chief

com pla int s of a soft gap on rig ht side of hea d,

seizures and residual left hemiparesis. Examin

ation revealed a parietal bony defect with a

slack depression, in an alert girl walking inde

pendent ly . Neurological examinat ion showed

minimal left hemiparesis with pyramidal signsand mild re tardat ion. Skul l radiographs on

admission showed a gaping right parietal frac

ture with everted saucerized margins . CT

(Fig. 2) showed a leptomeningeal cys t under

lying the crania l defect and communicat ing

freely with the pcrimesencephalic cistern. As

ther e was evid ence of regr owth of bo ne edg es

(Fig, 2) a long with cont inued improvement in

her neurological status, it was decided to ob

serve. At 3-month follow-up the bone gap had

na r rowed .

Case 2. This 6-year-old girl presented withseizures and a 'soft area' over the right parietal

region, noticed for the last 4 years. A head

injury had occurred when the child was 10

months old. One year after the head injury the

parents noticed a soft, gradually increasing

bulge in the right parietal region which gradu

ally 'flattened* in time leaving a 'soft area'.

Th er e was no his tory of head ache o r vomit ing.

Examination revealed an alert, bright child. A

skull defect in the right parietal region measur

ing about 4 cm and covered by slack scalp

could be fe l t . Neurological examinat ion re

vealed minimal left hemiparesis with brisk tendon jerks . There was no papi l ledema. Skul l

rad iog rap h (Fig. 3) sho wed a gap ing fracture

in right parietal region. CT (Fig. 4) showed a

low density lesion of the und erl yin g brai n wit h

slight dilat ation a nd ipsilateral 'pull ing' of the

right lateral ventricle. At operation, a large,


6/12


k AFCG. 2, Case 1: CT scan showing lcptomening eal cyst

underlying cranial defect and its communi catio n with the

perimcscncephalic cistern (arrow). Note regrowth of

fracture edges.

righi fronto-parietal scalp flap was raised.

Dense adhes ions between the scalp and un

derlying brain were dissected. Fracture edgeswere nibbled to expose normal dura . Tissues

were abnormally vascular and bled excessively.

Duroplasty and acrylic cranioplasty was car

ried out. Postoperatively the patient did very

well and was discharged home on phenytoin.

Three years la ter , she is asymptomatic and

free of seizures.

Case 3 . This 6-month-old girl was seen in the

neurosurgical clinic with the history that she

fell and struck the back of her head on a

concrete floor at the age of 1 month. Shortlyafterwards, a bulge was noticed in the left

occipi to-parie ta l region. This bulge became

progressively larger and tense. On admission

the child was irritable, refused feeds and had

been vomiting for past few days. Skull radio

graphs showed a widely gaping wedge-shaped

bone defect with extensive resorption in the

left occipito-parietal region. CT (Fig. 5a and

b) showed a large porencephal ic cys t commu

nicat ing with the occi pital ho rn of a dil ated left

la tera l ventr ic le and hernia t ing through the

wide bony gap into the tense occipital bulge.

The chi ld was t rea ted with ventr iculo-peri-

toneal shunt following which the occipital

bulge and hydrocephalus resolved. At fol low-

up examinations at 3 and 6 months, the child

was thriving, the occipital bulge had disap

peared and the bone defect was much smaller,

FlG. 3. Case 2: skull radiograph y, lateral view, sho win g

a widely gaping parietal fracture.

F l G . 4. Case 2:CT scan showing the right parietal bone

defect and the underlying low-density brain lesion.


7/12

6 7 4 Naim-Ur-Rahman et al.

FI G. 5. (a) and (b) CT scans sho wn a large left occip ital

ventricle (a) and herniating, through the wide bony gap

with definite eviden ce of bo ne re- grow th at the

fracture edges.

Case 4. This 3-year-old girl was originally

admitted and treated elsewhere for a linear

fractu re of left front o-par ietal reg ion. Seven

months after the original head injury, she was

admit ted to our neurosurgical uni t because a

bulge had developed over the left forehead

which became progressively larger. There was

a his tory of occas ional headaches , vomit ing,

seizures and progressive right hemiparesis dur

ing the preceding 3 months . On examinat ion

there was a tense linear swelling in the left

forehead extending from the left fronto

parie ta l region to the supra-orbi ta l margin

and ro ot of the no se. T he mar gin s of the

underlying skull defect could be palpated. She

had mil d weakn ess of right ar m and leg but

no pa p i l l ed em a . Sku l l rad iograph (F ig . 6 )

showed a linear defect in the left fronto

parietal region extending to the supraorbital

margin. CT (Fig. 7) showed the gaping frac

ture and an underlying low density brain

les ion. At opera t ion, a large frontoparie to-

temporal sca lp f lap was ra ised. Underneath

the flap an adhe ren t linear bulge of gliotic

brain was seen between the gaping fracture

edges . This hernia ted cerebra l t issue , extend-

porcnccphalic cyst communicating with a dilated lateral

(b).

ing from coronal suture to the supra-orbital

margin, was tense, congested and bled easily.

Dural repair with fascia lata and craniopiasty

with methyl methacryla te was carr ied out . The

pos topera t ive course was uneventful and the

chi ld was discharged hom e, free of hea dach e,

but with res idual mild r ight-s ided weakness .

Fol low-up a t 2 years showed that the im

planted plastic was loose and bulging over a

tense cystic swelling. Reoperation was refused.

Case J . The patient was originally admitted to

the neurosurgical unit at the age of 9 months

following a road traffic accident. On ad

miss ion, she was drowsy, but without any ab

normal neurological f indings . A radiograph of

the skull show ed an obl iquely place d fissu re

fractur e of the skull crossin g the m idli ne just

above torcula and CT showed this fracture

with min ima l cont usi on of the occipital lobes

(Fig. 8). The baby recovered rapidly from the

head injury and was discharged home after 5

days. Six months later (at the age of 15months) she was re-admitted with a tense

swelling in the region o f the occi pital fractur e

site and a susp icio n of progressi ve visual loss.

Th e occipital swelling ha d been gradual ly en

larging during the weeks prior to re-admiss ion.

Examinat ion now revealed that a l though the


8/12


FlG. 6. Case 4: skull radiograph, AP view, showing a

gaping linear defect (arrows) in the fronto-parictal

region.

FI G. 7. Case 4: CT scan sho win g the left frontal growing

fracture (arrows) and the underlying low density brainlesion.

child could see, the vision was clearly defective

as shown by her inability to fixate and lack of

reac tion to visual stimuli. Re act ion of the

pupils to the light was very sluggish but equal.

Visual evoked potentials (VEP) confirmed

cortical blindn ess. Plain radio gra phy 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 port ion of the occipit al bo ne an d und erl ying

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

wate r-t ight repair of the du ral defect was

achieved using a pericranial graft and a fresh

cranioplas ty was performed. The pos topera

t ive course w as uneventful a nd the wo un d

healed satisfactorily. Review 3 years later

showed defective vision.

Case 6. This child was hospitalized for 3 days

for hea d injury at the age of 5 m on th s. Sk ull

radiography and CT showed a left parieto-oc-

cipital fissured fr acture of skull with mi nim al

underlying contus ion (Fig. 11). Nine months

later she presented with a large skull defect

an d tense scalp sw ellin g at the site of the

fractu re, alon g wit h increasingl y frequ ent

seizures and delayed speech. Radiography now

showed a large, gaping skull defect at the siteof original fractur e (Fig. 12) and CT showe d

the gap ing fracture with hyp ode nsi ty of the

under lying bra in an d di la ta t ion of the ips i la t -

eral ventricle (Fig. 13). Sur gery was refused in

spite of progr essive neu rolog ical and radiolo gi

cal deterioration.

Case 7. A 39-y ear-o ld wom an 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 pariet al defect (Fig. 14), CT sho wed the

skul l defect and underlying leptomeningeal

cys t (Fig. 15). Durocran iopl as ty was s t ra ight

forward, a nd resul ted in resolut ion of hea d

ac he and clo sur e of th e skull defec t.


9/12

6 7 6 Naim-Ur-Rahman et al.

FlG. 8. Case 5: CT scan at the tim e of initial trauma

showing right occipital linear fracture.

FIG,9 , Case 5: skull radiography 6 mon ths later sho win g

large occipital bony defect with scalloped margins.

Discussion

Growing skull fracture has been described in

the literature as an entity synonymous to a

leptomeningeal cys t ,2

' ' ' '9

T hus , a pos t t rauma t icextra axial leptomeningeal cyst was assumed

to be responsible for the progressive enlarge

me nt of the skull fracture. T h e cases descri bed

here suggest that the leptomeningeal cyst is

not a consistent feature and that a variety of

progressively evolving morphological and

pathological changes in the underlying bra in

may play an important role in the genesis of

growing frac tures . Morphological ly , the pre

dominant factor responsible for fracture

growth may lie in the subarachnoid space (a

leptomeningeal cys t) , cerebrum (hernia ted

brain) or ventricle (dilated underlying ven

tricle with porencephalic cyst). These events

constitute the morphological basis for the frac

ture types I, II and III, respectively.

At the initial traum a, disto rtio n of the mal

leable infant skull on impact generates press

ure fields within the cranium, leading to a

skull fractu re and tea ring of the tightly adh er

en t unde r ly ing dura .1 0 , 1 1

Six of the seven pa

tients in our scries and most in other series3

were child ren. T hu s, malleabi lity of the infant

skull and tighter adhe ren ce of dura to t he bone

in chi ldren may account for the common

occ urr enc e of grow ing fractures in this age

g r o u p ,1 2

Pathog enes is of the lepto mening eal cys ts , as

seen in our cases 1, 5 and 7, is well described

e l s e w h e r e .2 , 9

In type II fractures, as seen in our

cases 2, 4 and 6, cerebral pulsations erode the

fracture edges, and drive the cerebrum

through the dura l vent and bony gap. With

t ime, the hernia t ing and the underlying bra in

suffers progressive damage as shown by local

atrophy and cephalomalacia. In type III frac

tur e (cases 3 an d 5), the und erl ying ventricle

expands into a porencephal ic cys t . The ent i re

ventricle may dilate as was seen in case 3 or

jus t the o n e h o r n subjac ent to the g rowing

fracture may dilate as occurred in case 5. In

these cases, the porencephalic cyst extends

from ventricular wall through the skull defect

and into the subgaleal space, and is roofed by

a th in layer of soft ened gliotic cor tex .

In mos t of the r epor ted cases t he initial he ad

injury was a minor one and focal neurological

deficits were rare.1 1

Th us , at the tim e of initial

skull fracture, only two of our patien ts sh owe dminimal hemipares is . However, over the ensu

ing weeks or months, all of these children

sho wed e viden ce of mo re or less progr essive

neurological deficits . Neurological status and

fracture st abilized, after a per iod o f pr o

gression and growth, in two children. This


10/12


FlG. 10. Case 5: six months later. CT scan showing

marked wid eni ng of the occipital fracture with scall oping

of the margins and right occipita l porenc eph aly and a left

occipital leptomeningeal cyst.

resolution was quite dramatic in case 1, and

was thought to be due to rupture and drainage

of the leptomen ingeal cys t into the peri mesen -

cephalic cistern (Fig. 2),

The natura l his tory and temporal course of

the growing skull fractures varied from case to

case . The rapid progress ion with ra ised ICP

seen in case 3, and spontaneous arrest and

healing seen in case 1, appear to be the two

ends of a spect rum. Gradual ly progress ive

neurological defic i ts with increas ing underly

ing bra in damage was the more common oc

curr ence a nd was seen in four of ou r pati ent s.

In active growing skull fractures, a tense

overlying scalp bulge may indicate raised ICPwhich may be caused by a tense lep-

tomeni ngeal / porcnc cphal i c cys t , or pos t t rau

m a t i c h y d r o c e p h a l u s .1 3

Slack scalp depression

at the fracture site wit h evidence o f bo ne re-

growth and fracture healing, along with the

arrest of the previousl y progr essive neur olo gi

cal deficits indicates spontaneous resolution of

a leptomeningeal cyst, as was seen in case 1.

Gradually progressive focal neurological

deficits , seen in four children, coincided

closely with th e incr easing se para tion of the

bone edges at the fracture site and CT evi

dence of extens ion of the underlying bra in

da ma ge . Th e nat ure of thes e focal deficits

depended on the frac ture s i te . Thus , the two

children with occipital fractures (cases 3 and

5) suffered progressive visual loss, while he mi-

paresis was seen in the cases with fronto

parietal fractures.

Skull radiography and CT were the two

most useful investigations for the diagnosis

an d mon ito rin g of grow ing skull fractures.

Th us , at the time of the initial tr aum a, all the

seven patients had skull radiographs which

show ed linear fracture s. Th e initial hea d injury

was not cons idered serious enough to warrant

CT in the first instance, except in cases 5 and

6 whe re CT at the time of tr au ma conf irme d

the fissured skull fractures without evidence of

s ignif icant contus ions or damage to the under

lying bra in (Figs. 8 an d 11). Del aye d CT

sho wed the fracture grow th (Figs. 10 an d 13)

and, mor e import ant ly , appea rance of exten

sive fresh lesions with marked and possibly

cont inuing damage to the underlying bra in

(Figs. 1 0 an d 13). CT correc tly dem on str at ed

the nat ure and ex tent of the intracrania l path

ology includi ng areas of cephalomalacia , sub

dural , leptomeningeal and porencephal ic

cysts, as well as ventricular dilatation (com

plete or only one horn).

Becau se of the variab le pathologi cal

f indings , the s tandard surgical procedure de

scribed in the l i te ra ture2

'1 1 , 1 4

for the t rea tment

of the gr owi ng skull fr actures is no t justifiable

or applicable in all the cases. Standard surgical

appr oach involves resect ion of the lept o

meningeal cys t and hernia ted bra in, repair of

the dural defect with a graft and cranio

p i a s t y2 , 1 1

For the s t ra ightforward cases without

any evidence of raised IC P, s uch as our cases

2 and 7, this procedure is curative. We have

used pericranium/fascia la ta and methyl

methacryla te to repair dura l and crania l de

fects in our cases; but others have used split


11/12


FI G. 1 1 . Case 6: CT scan at the time of initial trauma

showing left parieto-occipital fracture with minimal

underlying contusion and normal ventricular system.

FLG. 1 2. Case 6: skull radiograph, 9 mont hs later

show ing large, gapi ng skull defect at the site of original

fracture.

calvarial bone, ribs, iliac crest and metallicmateria ls with sa t is fac tory resul ts .

1 5

"1 8

H o w

ever, ch ild ren un de r 2 year s of age have a skull

bone thickness that is too difficult to split in

orde r to repair the defect .1 8

In some pat ients ,

such as our case 4, the dural defect extends

well beyond the skull defect, necessitating

FlG. 13. Case 6: CT sc an 9months posttrauma showing

gaping fracture with hypoden sity of underlying brain and

dilatation of the ipsilateral ventricl e.

FIG . 1 4 . Case 7: skull radiograph showin g gaping skull

defect, right parietal region.

rongeuring bone edges for long dis tances inorder to expose reasonable dura l edges to

which the graft can be stitched. In others, such

as our case 5, one may be obliged to resect the

cortex which roofs the hernia t ing poren

cephalic cyst. This extensive enlargement of

the skull defect an d resectio n of the possibly


12/12


FlG. 15. Case 7: CT scan sho win g right parietal skull

defect overlying a leptomeningeal cyst.

functiona l a nd viable a reas of the infant brain

appear to be somewhat excessive. In these

ci rcumstances, the modif ied method for re

pairing this defect, as described by Halliday et

al.,"* seems more appropriate. This technique

involves mobi l izing the per icran ium ci rcum-

fercntially ar ou nd the edges of the bone defect

an d reflecti ng it over the site of the du ra l

defect to provide t issue for repair, 1

In growing skull fractures associated with

raised ICP, shunt surgery should be con

sidered as an init ial or alternative procedure,

as i t ma y resu lt in res olut ion of rais ed IC P,

dis appea ran ce of scal p swellings and re growth

of bon e edges at the fracture si te ; 1 3 as i l lus

trated by case 3.

Recurrence after surgical repair in two of

our pat ien ts and o ther repor ted cas es 1 3 co r r e

lated with failure to secure watertight dural

clos ure or failure to addr ess the raised IC P.

Bec au se of the kno wn risk of frac tur e

growth along with the frequently progressive

natu re of brain dam age an d neuro logical

deficits, children with linear skull fractures

should be examined clinically 2-3 months

later to chec k for eviden ce of growing fractur e.

If a scal p bul ge or gapi ng bone defe ct is foun d,

radiography and CT should be repeated. If

growing skull fracture is confirmed, surgical

repair should be advised.

Address for correspondence: P ro fesso r Naim -Ur-

Rahm an , Division of Neur os ur ger y, Colle ge of

Medicine, King Saud University & King

Khalid University Hospital, PO Box 2925,

Riyadh 11461, Sau di Ara bia.

References1 Scarff TB , Fin e M, Growi ng skull fractures of

childh ood. In: Wilkins R H , Rengachary SS cds.

Neurosurgery, Vol. 2. New York: McGraw Hill,

1985; 1627-8.

2 Long DM , Kieffer SA, Chou SN . Leptomeningeal

cyst. In: Youmans JR ed. Neurological surgery,

Vol. 5. Philadelphia: WB Saunders, 1982; 3245

50.

3 Len de R, Ericks on T. Growi ng skull fractures of

childhood. J Neurosurg 1961; 18:479-89.

4 Soule A, Whit comb B. Extensive erosion of the

base of the skull from a lept omen inge al cyst. Report

of a case. Arch Neur ol Psychiat 1946 ; 55:3 82- 7,

5 Halliday AL, Chapman P H, He ros RC. L ep

tomeningeal cyst resulting from adulthood trauma:

case report. Neurosurgery 1990; 26:150-3.

6 Ramamu rthi B, Kalyanar aman S. Rati onale fot

surgery in growing fractures of the skull. J Neuro

surg 1970; 32:427-30.

7 Chorobs ki J, Dav is L, Cyst forma tion of skull.

Gynecol Obstet 1934; 58:12-31.

8 Stein EM , Tenner M S: Enla rgement of skull frac

tures in childhood due to cerebral herniation. Arch

Neurol 1972; 26:137^3.

9 Tavcras JM, Wo od EH . L eptomeni ngeal cyst.

Diagnostic neuroradiology. Baltimore: Williams &

Wilkins, 1 976: 2(IV): 105 5-9 .

10 Ommaya AK, Grubb RL, Naumann RA, Coup and

counter-coup injury: observations on the mechanics

of visible brain injuries in the rhesus monkey. J

Neurosurg 1971; 35:503-632,

11 Bruce DA. Growing skull fracture: special consider

ations of the pediatric age group. In: Cooper PR cd.

Head injury. Baltimore: Williams & Wilkins, 1982;

318-19.

12 Rahimizadeh A, Had dadia n K. Bilateral traumatic

leptomeningeal cysts. Neurosurgery 1986; 18:385

7,

13 Sharma RR, Chandy MJ. Shunt surgery in growing

skull fractures: report of two c ases. B r J Neu rosu rg

1991; 5:93-8.

14 McLa urin R, McLe nn an J. Diagnosis and treat

ment of head injury in children; In: Y oum ans JR

ed. Neurological surgery, Vol. 4. Philadelphia: W B

Saunders, 1982; 2097-9.

15 Guyuron B, Shafrom M, Columbi B. Management

of extensive and different cranial defects. J Neuro

surg 1988; 69:210-12.

16 Timmons RL. Cranial defects and their repair. In:

Youmans JR ed. Neurological surgery. Philadel

phia: W B Saunders, 1982; 2228-50.

17 Malis LI. Titanium mesh and acrylic cranioplasty.

Neurosurgery 1989; 25:351-5.

18 Posn ick JC, Goldstein JA, Armstrong D, Rutka JT.

Reconstruction of skull defects in children and ado

lescents by the use of fixed cranial bone grafts:

Ijmg-term results. Neurosurgery 1993; 32:785-91.

growing skull fractures classification and management

Documents