Leptomeningeal Cyst and Vacuum Extraction

Abstract

A single case of growing skull-fracture and intracranial porencephalic cyst caused by vacuum extraction is on record (1). We report an infant who developed a large extracranial pseudomeningocele after tedious ventouse extraction.The six-month-old male infant was first examined at our outpatient clinic because of a large rapidlygrowing cranial bulge ( Fig. 1). He was born in another hospital by a nulliparous mother after an uneventful pregnancy. Labour had been induced electively, at 39 weeks of gestation. Second-stage delay (90 min) due to persistent occiput-posterior position prompted the consulted obstetrician to perform a vacuum extraction. The procedure was tedious and complicated by multiple episodes of cup detachment. At birth, the neonate (birthweight 4 150 g; head circumference 36 cm) was very lethargic, but cried immediately. Apgar scores are unknown. A large left parieto-occipital cephalhaematoma was noticed. Be-Acta Paediatr Scand 79 Short communication 233Fig. 2. CT-scan of the brain. Adapted oblique coronary incidence (see text).Growing skull-fracture is a well-known, albeit uncommon complication of calvarian fracture with underlying dural tear in infancy and very early childhood (2). In almost all reported cases the cause of injury was a fall from a height or a car accident (2). Growing skull fracture related to forceps delivery has occasionally been reported (3)(4). We report an infant with a large-sized rapidly progressive extra-cranial leptomeningeal cyst following difficult ventouse delivery. When incorrectly performed this procedure may inflict severe mechanical trauma on the baby. The paediatrician must be familiar with this rare complication because early recognition and treatment may prevent the occurrence of irreversible neurological sequelae, as "active" brain damage continues after the initial injury (5).

Growing skull fractures (craniocerebral erosion)

“…Falling appears to be the most frequent cause of injury. Motor vehicle accidents, child abuse, birth injuries, and previous cranial surgery can also lead to GSF [4,7,13,25,[34][35][36][37][38][39][40][41][42]. Moss et al [43] even reported intrauterine GSF.…”

“…Moss et al [43] even reported intrauterine GSF. Neurological deficits such as hemiparesis, squinting, and visual field defects may accompany the scalp swelling [4,7,16,27,30,35,37,41,44,45]. Symptoms and signs may also vary with the growing fracture's location.…”

Rapid Evolution of a Growing Skull Fracture after Vacuum Extraction in Case of Fetal Hydrocephalus

“…The case reported by Hansen et al [2] was explained by repositioning the vacuum cup too anteriorly, thereby disrupting the coronal suture. The case decribed by Vanhaesebroeck et al [3] was complicated by 'multiple episodes of cup detachment'. Also in our case VE was not without difficulty, with the possibility of the cup being placed too anteriorly resulting in abnormal force vectors.…”

“…In almost all reported cases the cause of injury was a fall from a height or a car accident and it takes several months to years for the clinical picture to evolve [11]. Only 5 cases have been described following traumatic birth: 2 after forceps delivery [12] and 3 after VE [2,3]. One congenital GSF after prenatal trauma has also been described [ 13].…”

“…We present a case of a vacuum extractor-induced growing skull fracture (GSF) with extensive brain damage. To our knowledge only Hansen et al [2] in 1987, Vanhaesebroeck et al [3] in 1990 and Papaefthymiou et al [4] in 1996 have previously described a GSF after VE, making this the first case with associated fetal hydrocephalus. …”