Growing skull fractures: classification and management

Abstract

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 of growing skull fractures were recognized. In type I (n = 3) a leptomeningeal cyst, in type II (n = 3) damaged and gliotic brain, and in type III (n = 2) a porencephalic cyst extended through the skull defect into the subgaleal space. A combination of type I and type III co-existed in one patient. Initial head injury and neurological deficit were judged to be mild to moderate in all the seven cases. Continued 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.

Vertical Gaze Palsy in a case with Growing Skull Fracture and Porencephalic Cyst

“…4,5 It is generally recommended that in the presence of increased intracranial pressure (ICP) or progressive neurological deficits, surgical modes be adopted to treat these cysts by shunt surgery with or without closure of the defect by a duro-cranioplasty. [1][2][3]5 The vertical gaze palsy alerted us to the possibility of an intracranial lesion in the present case. Subtle morphological changes in the brain have been observed in patients with infantile esotropia.…”

“…1 To date there have been eight cases reported in the literature, [1][2][3][4] but to our knowledge this is the first report in a child.…”

“…1À3 These are commonly seen in children, possibly because of the greater malleability of the infant skull and the tighter adherence of the dura to the bone. 1 This growth of the fracture may cause atrophy of the underlying cerebral tissue along with the formation of a porencephalic cyst, which may extend through the skull defect into the subgaleal space, all of which may result in progressive neurological deficits. [1][2][3] We report an unusual case of a young boy harbouring a large porencephalic cyst, who was found to have vertical gaze palsy on ocular examination in the absence of other neurological signs and symptoms.…”

“…It remains controversial whether a duro-cranioplasty should be performed prophylactically in a patient such as this to prevent any future deficit, [1][2][3]5 or whether he should be kept under close monitoring and be operated only if necessary. 8,9 The role of strabismus surgery also remains controversial.…”

“…1,4 These are usually associated with various ophthalmic and neurological signs, mainly compressive in origin. 4,5 It is generally recommended that in the presence of increased intracranial pressure (ICP) or progressive neurological deficits, surgical modes be adopted to treat these cysts by shunt surgery with or without closure of the defect by a duro-cranioplasty.…”