Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 59, Num. 3, 2011, pp. 424-428

Neurology India, Vol. 59, No. 3, May-June, 2011, pp. 424-428

Brief Report

Surgical treatment and results in growing skull fracture

Batuk Diyora, Naren Nayak, Hanumant Kamble, Sanjay Kukreja, Gargi Gupte, Alok Sharma

Department of Neurosurgery, L.T.M.G. Hospital, Mumbai, India

Correspondence Address:Batuk Diyora Department of Neurosurgery, 2nd Floor, L.T.M.G. Hospital, Sion (W), Mumbai - 400 022 India bddiyora@hotmail.com

Date of Submission: 07-Jan-2011
Date of Decision: 01-Feb-2011
Date of Acceptance: 07-Feb-2011

Code Number: ni11122

PMID: 21743175

DOI: 10.4103/0028-3886.82762

Abstract

Keywords: Growing skull fracture, head injury, leptomeningeal cyst

Introduction

Growing fracture of skull is an uncommon, interesting, and challenging en tity. Decision making in a given case is difficult and inappropriate selection results in a dissatisfactory result. Progressive pulsatile head swelling is the most common presenting feature. Clinical examination reveals a pulsatile swelling which becomes tense as the child cries. Bone margins can be felt around the edges. History of head trauma can be elicited in nearly all cases. ^[1],[2] Computed tomography (CT) of the head confirms the diagnosis and repair should be carried out as early as possible. Here, we report 11 patients with growing skull fracture operated at our centre and discuss the pathology, principles of management, and review of the literature.

Material and Methods

This was a retrospective analysis of case records of 11 patients with growing skull fracture treated between January 2005 and December 2009. Details of history, clinical features, radiological finding, surgical indications, and type of surgery as well as clinical outcome were analysed [Table - 1].

Results

The age of patients at presentation ranged from 9 months to 12 years (mean age, 3 years). Of the 11 patients, 6 were females and 5 males. History of trauma was present in all patients. Eight patients had parietal bone fracture, two had basifrontal fractures and one had an orbital roof fracture. The onset of symptoms after head trauma ranged from 2 weeks to 4 years (mean, 11 months). The duration of symptoms before seeking medical help ranged from 2 weeks to 3 years. Scalp swelling [Figure - 1] was the presenting feature in four patients, seizure in one and both in three patients. Two patients presented with proptosis and one with eyelid swelling. Plain X-ray skull showed a wide bony defect [Figure - 2]. Brain magnetic resonance imaging (MRI) was performed in one patient who showed presence of leptomeningeal cyst, underlying brain parenchymal injury and underlying ventriculomegaly [Figure - 3]. CT scan of the brain was performed in all patients, and all of them showed the presence of growing skull fracture; leptomeningeal cyst in two patients [Figure - 4]a and b, underlying brain damage or gliosis in seven patients [Figure - 5], and porencephalic cyst in two patients [Figure - 6]. All patients underwent surgical repair of growing skull fracture. Indications for surgery were progressive scalp swelling in nine patients and proptosis in two. The operative procedure included definition of the bone and dural margin with primary duraplasty using the pericranial flap [Figure - 7]a and b. Cranioplasty was done in five patients, using the rib graft in two and split calvarial graft in three patients. One patient underwent cranioplasty using the methyl methacrylate [Figure - 8]a and b. Postoperatively, one patient developed cerebrospinal fluid (CSF) leak, which required re-exploration and repair with tissue glue. Two patients had postoperative seizures, which were controlled with antiepileptic drugs (AED). Good clinical outcome was obtained in all patients.

Discussion

Growing skull fracture is a rare neurological complication and accounts for 1.2-1.6% of the head injury patients. ^[1],[2] The term "growing fracture" has been coined by Pia and Tonnis. ^[3] "Leptomeningeal cyst" is another term commonly used for this entity, described by Dyke because of its frequent association with a cystic mass filled with CSF. ^[4] The term "pseudo encephalocoele" is also suggested as it more closely describes the pathology, as compared to "growing fracture" or "leptomeningeal cyst". It is commonly seen in people below the age of one year (50%), and nearly 90% of the patients are below the age of 3 years, after which the condition is rare. ^[5],[6] A majority of cases occur following fall, vehicular accident, and child abuse; cases following difficult vacuum extraction and corrective surgery for craniosynostosis have also been described. ^[7],[8] Growing skull fracture commonly involves the calvarial bones. Rarely, it can occur at basiocciput and orbital roof. ^[9]

The exact etiopathological process of growing skull fracture is unclear. The single most important factor in the pathogenesis of growing skull fracture is dural tear. ^[10] In 1961, Lende and Erickson reviewed the literature on this subject and emphasised on four essential features: (1) skull fracture in infancy or early childhood; (2) dural tear at the time of fracture; (3) brain injury underlying the fracture; and (4) subsequent enlargement of the fracture resulting in a cranial defect. ^[4] Combination of these factors alters the normal distribution of intracranial pressure and the bony defect acts like a neosuture through which the dura along with brain herniates. Uncertainty remains as to why the defect should enlarge, and having reached a certain size, why it should cease to grow? In 1967, Goldstein published an animal experiment with results suggestive of a high incidence of enlarging bone lesions in groups where the defect was not limited to the dura matter alone. In the group with dural tear but without damage to the arachnoid or pia or to the underlying brain, there was no significant incidence of growing fracture. ^[11]

We believe that in infants and young children, the dura remains firmly adhered to the bone. During trauma, which leads to fracture skull, the underlying dura gets torn. The developing brain exerts continuous pulsatile pressure, which widens the defects. Associated injury to the leptomeninges and brain facilitates the process and increases the chance of growing fracture of skull. There is progressive resorption of dural and bone edges, which leads to increase in size of the defect and cranial asymmetry. Repair of the defect should therefore be carried out as soon as the diagnosis is made. Delay in the procedure makes the operation more difficult. It may also increase neurological deficits by producing parenchymal herniation with subsequent gliosis.

Every infant/child who has sustained the trauma should undergo a plain X-ray to rule out any fracture. If a fracture is found, CT scan should be done to rule out injury to the brain. Based on the CT appearance, growing skull fractures are subdivided into three types: Type I refers to growing skull fracture with a leptomeningeal cyst, which may be seen herniating through the skull defect into the subgaleal space. Associated brain damage or gliosis is seen in type II, while type III is associated with porencephalic cyst. ^[2] In our series, two patients had type I, seven had type II and two had type III growing skull fracture. MRI delineates the dural and parenchymal lesions in greater detail. Cranial Doppler studies have been used for an early diagnosis. ^[12]

At operation, the scalp can be easily stripped off the swelling. The bone is drilled all around the swelling to identify the dural edge. The dura is separated from underlying brain and is repaired using fascia lata graft or artificial dura. If possible, the skull defect is closed using split-thickness bone flap taken from appropriate site or rib graft.

Epilepsy, hemiparesis or atrophy of limbs are manifestations of the initial cerebral damage ^[13] and may not be due to growing fracture of skull. Therefore, these may not improve after operation. Although most authors advocate surgical treatment for growing skull fracture, Ramamurthi and Kalyanaraman have described four patients with growing skull fracture not treated by surgery. ^[14]

References

1.	Sener RN. Growing skull fracture in a patient with cerebral hemiatrophy. Pediatr Radiol 1995;25:64-5.  Back to cited text no. 1
2.	Naim-Ur-Rahman, Jamjoom Z, Jamjoom A, Murshid WR. Growing skull fractures: Classification and management. Br J Neurosurg 1994;8:667-79.  Back to cited text no. 2  [PUBMED]
3.	Pia HW, Tonnis W. Growing skull fractures of childhood. Zentralbl Neurochir 1953;13:1-23.  Back to cited text no. 3
4.	Dyke CG. The roentgen ray diagnosis of diseases of the skull and intracranial contents. In: Diagnositc Roentgenology, Vol. 1, pp. 1 - 34. Edited by W. Golden. Williams and Wilkins: Baltimore; 1938.  Back to cited text no. 4
5.	Lende RA, Erickson TC. Growing skull fractures of childhood. J Neurosurg 1961;18:479-89.  Back to cited text no. 5
6.	Iplikcioðlu AC, Kökes F, Bayar A, Buharali Z. Leptomeningeal cyst. Neurosurgery. 1990;27:1027-8.  Back to cited text no. 6
7.	Papaefthymiou G, Oberbauer R, Pendl G. Craniocerebral birth trauma by vaccume extraction: A case of growing skull fracture as a perinatal complication. Childs Nerv Syst 1996;12:117-20.  Back to cited text no. 7
8.	Yamamoto M, Moore MH, Hanieh A. Growing skull fracture after cranial vault reshaping in infancy. J Craniofac Surg 1998;9:73-5.  Back to cited text no. 8
9.	Parmar RC, Bavdekar SB. Images in radiology: Type III growing skull fracture. J Postgrad Med 2000;46:130-1.  Back to cited text no. 9  [PUBMED]
10.	Taveras JM, Ransohoff J. Leptomeningeal cysts of the brain following trauma with crosion of the skull. A study of seven cases treated by surgery. J Neurosurg 1953;10:233-41.  Back to cited text no. 10
11.	Goldstein F, Sakoda T, Keped JJ, Davidson K, Brackett CE. Enlarging skull fractures. Anexperimental study. J Neurosurg 1967;27:541-50.  Back to cited text no. 11
12.	Yoshioka H, Sakoda K, Kohno H, Hada H, Kurisu K. Usefulness of color Doppler sonography in a growing skull fracture: Case report. J Trauma 1997;42:144-6.  Back to cited text no. 12
13.	Tung M, Tan K. Growing skull fractures. Singapore Med J 1993;34:438-41.  Back to cited text no. 13
14.	B, Kalyanaraman S. Rationale for surgery in growing fractures of the skull. J Neurosurg 1970;32:427-30.  Back to cited text no. 14

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