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CASE REPORT |
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| Year : 2020 | Volume
: 15
| Issue : 3 | Page : 261-265 |
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Arrested hydrocephalus complicated by growing skull fracture - A case report with review of literature
Ashok Kumar, Gaurav Jaiswal, Vivek K Kankane, Pavan K Kumar, Tarun K Gupta
Department of Neurosurgery, RNT Medical College, Udaipur, Rajasthan, India
| Date of Submission | 24-Jun-2018 |
| Date of Decision | 18-Nov-2019 |
| Date of Acceptance | 25-May-2020 |
| Date of Web Publication | 06-Nov-2020 |
Correspondence Address:
Dr. Gaurav Jaiswal
Associate Professor, Department of Neurosurgery, RNT Medical College, Udaipur, Rajasthan.
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jpn.JPN_100_18
 Abstract | | |
Growing skull fracture (GSF) is an extremely uncommon entity and accounts for less than 1% of the skull fractures. This type of fracture is commonly seen in children of less than 3 year of age and two third of them occur in less than one year of age. Occurrence of GSF is higher in infancy and early childhood because of rapid growth of brain and skull take place in initial two year of the life. Dural tear is most common etiological factor that leads to growing skull fracture. Growing skull fracture with arrested hydrocephalus is a rare association and has been described only once in literature. We hereby, are reporting a case of one year child presented with gradual progressive head enlargement with progressive subgaleal swelling over left parietal region. patient sustained head injury 4 month back due to fall from bed. After all relevant radiological examinations, cyst excision and water tight dura closure was done. Patient improved and till last follow up there was not any recurrence of cyst.
Keywords: Arrested hydrocephalus, growing skull fracture, trauma
How to cite this article:
Kumar A, Jaiswal G, Kankane VK, Kumar PK, Gupta TK. Arrested hydrocephalus complicated by growing skull fracture - A case report with review of literature. J Pediatr Neurosci 2020;15:261-5 |
| Introduction | |  |
Growing skull fracture is a rare complication of pediatric head injury and occurs exclusively during the first 3 years of life. The occurrence of arrested hydrocephalus with growing skull fracture is rare association, and is reported only once in literature till now. Howship[1] was the first man who reported a patient with a growing skull fracture in 1816. He described a 9-month-old child in whom an enlarging defect in the parietal bone occurred after an injury. He mentioned that the incidence of growing skull fracture following head trauma is less than 0.05%–1.6%, after which the condition is rare.[2] A number of terms have been used to describe growing skull fracture such as traumatic ventricular cysts, craniocerebral erosions, cranial malacia, post traumatic leptomeningeal cyst (PTLMC), diploic cyst, and cerebrocranial erosion. Taveras and Ransohoff,[3] in 1953, described cysts were caused by cerebrospinal fluid (CSF) that was trapped in a herniated section of arachnoid membrane and was enlarged because of a ball valve mechanism. This late complication is also known as leptomeningeal cyst because of its frequent association with a cystic mass filled with CSF.[4] They can present with pulsatile, soft subgaleal swelling, headache, neurological deficit, and seizures.
| Case Report | | |
A 1-year-old male child was admitted with complaints of gradual enlargement of head of 8-month duration and progressive swelling over left parietal scalp of 3-month duration. The child fell down from the bed at the age of 4 months with a history of transient loss of consciousness. He was hospitalized elsewhere for one day and was discharged in normal neurological condition. On present examination, a single, oval-shaped, soft, nontender, cystic, pulsatile, transilluminant, and compressible swelling of size approximately 10 cm × 8 cm × 6 cm over left parietal region was observed [Figure 1]. The patient was conscious, and the swelling had postural variation. Swelling got reduced in size in upright position as compared to supine position. The patient had no prior history of seizure, vomiting, or any type of neurological deficit. He was investigated by using plain X-ray, which demonstrated fracture site with an area of lucency over parietal bone with erosion of both table of bone. Non-contrast CT (NCCT) brain revealed dilated ventricular system, communicating with the calvarial defect over left parietal a bone through which fluid-filled cavity was protruding as a subgaleal CSF collection [Figure 2]. Three-dimensional (3D) computed tomography (CT) of head revealed a well-defined left parietal bone defect with widely open anterior fontanel [Figure 3]. The patient was taken for surgery; the scalp flap was raised, and a fluid-filled, oval-shaped cyst of arachnoid membrane was found protruding through the defect of size 5 cm × 3 cm with irregular margin [Figure 4]. Margin of bone defect was drilled all around the cystic cavity. Dural margin was followed circumferentially and striped off from bone margin. There was no evidence of underlying brain gliosis, infract, or necrosis. Watertight dural closure was done by using pericranium graft. Postoperative scan revealed resolving hydrocephalus without any evidence of residual subgaleal swelling [Figure 5]. Child was doing well without any complication with resolved parietal swelling during his first follow-up.  | Figure 2: NCCT brain revealing dilated ventricles communicating with cyst
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| Results | | |
The procedure as well as postoperative period was uneventful. The patient was discharged with satisfactory condition with routine follow up advice. He is on regular follow-up without any further neurological complication or recurrence of swelling. Result was overall good.
| Discussion | | |
The term “growing skull fracture” was coined by Pia and Tonnis. Leptomeningeal cyst is another term commonly used for this entity, as described by Dyke.[5] Lende and Erickson[6] reviewed the literature on this subject and emphasized 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. Liu et al.[7] divided the progression of growing skull fracture (GSF) into three stages during treatment of the disease. Stage 1 is from the time of injury to the time just before the enlargement of the fracture. Stage 2 extends from the initial fracture enlargement to 2 months after the beginning of enlargement. During this Stage 3, the bone defect becomes larger, and skull deformity and neurological disorder become severe if left untreated. There are two main hypotheses to elucidate why the incidence of GSF is higher in infancy and early childhood than that in adulthood. One hypothesis is that during the first 2 years of life, rapid growth of the brain and skull occurs; the dura mater adheres more tightly to the bone and thus is more easily torn when the skull is fractured.[8] The other hypothesis proposes that the skull is thinner, less stiff, and more deformable.[8] If complications (such as hydrocephalus or seizures) have occurred, Ventriculoperitoneal (VP) shunt placement or resection of the scar tissue inducing the seizures, respectively, should be performed. The most important step of surgery is watertight closure of the dural defect.[9] Skull defect is closed by using split-thickness bone graft or rib graft. Although most authors suggest surgical treatment for growing skull fracture, but Ramamurthi and Kalyanaraman[9],[10] have described four patients with growing skull fracture treated with conservative measures.
| Conclusion | | |
Growing skull fracture is a rare entity in the form of a complex disorder, including calvarial defect, underlying porencephalic cyst, and gliosis of brain that causes neurological deficit in child. Primary aim of management in such type of patient should be proper delineation of dural edge and watertight dura closure. After dural repair, patient should be strictly watched for the recurrence of swelling and any sign and symptom of raised intracranial pressure (ICP). If hydrocephalus is not subsiding, subduroperitoneal shunt placement should be performed. Patient may be taken for CSF diversion if there is CSF leak despite tight dura repair or concomitant hydrocephalus.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Howship J Practical observations in surgery, and morbid anatomy. London, UK: A. Strahan; 1816.  |
| 2. | Iplikcioðlu AC, Kokes F, Bayar A, Buharali Z Leptomeningeal cyst. Neurosurgery 1990;27:1027-8. |
| 3. | Taveras JM, Ransohoff J Leptomeningeal cysts of the brain following trauma with erosion of the skull. A study of seven cases treated by surgery. J Neurosurg 1953;10:233-41. |
| 4. | Khandelwal S, Sharma GL, Gopal S, Sakhi P Growing skull fractures/leptomeningeal cyst. Indian J Radiol Imaging2002;12:485-6. |
| 5. | Dyke CG The roentgen ray diagnosis of diseases of the skull and intracranial contents. In: Diagnostic roentgenology. Vol. 1. |
| 6. | Lende RA, Erickson TC Growing skull fractures of childhood. J Neurosurg 1961;18,pp.1-34. Edited by W. Golden. Williams and Wilkins: Baltimore; 1938:479-89. |
| 7. | Liu XS, You C, Lu M, Liu JG Growing skull fracture stages and treatment strategy. J Neurosurg Pediatric 2012;9: 670-5. |
| 8. | Gugliantini P, Caione P, Fariello G, Rivosecchi M Post traumatic leptomeningeal cysts in infancy. Pediatr Radiol 1980;9:11-4. |
| 9. | Ramamurthi B, Kalyanaraman S Rationale for surgery in growing fractures of the skull. J Neurosurg 1970;32: 427-30. |
| 10. | Kalyanaraman S Rational for surgery in growing fractures of skull. J Neurosurg 1970;32:427-30. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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