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NEURORADIOLOGY Table of Contents   
Year : 2002  |  Volume : 12  |  Issue : 4  |  Page : 485-486
Growing skull fractures/leptomeningeal cyst


Department of Radiodiagnosis, G.R. Medical college, Gwalior, India

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Keywords: Skull Fractures/DI, Skull Fractures/SU, Arachnoid Cysts, Skull/RA, Depression/CO, Encephalomalacia, Human, Infant, Case Report,

How to cite this article:
Khandelwal S, Sharma G L, Gopal S, Sakhi P. Growing skull fractures/leptomeningeal cyst. Indian J Radiol Imaging 2002;12:485-6

How to cite this URL:
Khandelwal S, Sharma G L, Gopal S, Sakhi P. Growing skull fractures/leptomeningeal cyst. Indian J Radiol Imaging [serial online] 2002 [cited 2014 Oct 22];12:485-6. Available from: http://www.ijri.org/text.asp?2002/12/4/485/28518

   Introduction Top


Growing skull fracture, recently termed as Craniocerebral Erosion, is a rare complication of skull fractures and mainly in infancy and early childhood. It is characterized by progressive diastatic enlargement of the fracture line. This late complication is also known as a Leptomeningeal cyst because of its frequent association with a cystic mass filled with CSF.


   Case Report Top


A 3-month infant was brought in with a history of fall 15 days back. The patient had a gradually increasing swelling over the left parietal region. The patient was conscious and there was no history of seizures or vomiting or any discharge from the ears or nose.

On physical examination a cystic swelling of approx. 8x6cms. In size was present over the left parietal prominence. The swelling was compressible but not tender. A bone gap was palpable. The anterior fontanelle was open wide. There were no focal neurological deficits.

A plain radiograph of the skull-left lateral view was obtained which confirmed a segmental fracture of the left parietal bone and also showed an oblong lucency with a soft tissue swelling over the fracture in the left parietal bone. The margins of the bone gap were everted. A low attenuation area of size 1.5x1.2 cms of CSF density was seen protruding through the gap on C.T. Examination, there was also widening of the sulcal spaces in the left parietal region.

The patient was operated upon and corrective surgery was done. There were no intraoperative or postoperative complications and the patient was doing fine as noted on the follow up visit at 1 month after the operation.


   Discussion Top


Growing skull fractures usually occur after severe head trauma during the first three years of life (particularly in infancy) and almost never after 8 yrs of life. Incidence reported is only.05 to.1% of skull fracture in childhood [1],[2]. During this stage, the brain volume is increasing rapidly which is in part responsible for their development. Though the development of growing skull fractures is multifactorial but the predominant factor in their causation is the presence of lacerated dura mater. The pulsatile force of the brain during its maximum growth will cause cerebral or subarachnoid herniation through the lacerated dura which causes the fracture in the thin skull to enlarge. This interposition of tissue prevents osteoblasts from migrating, inhibiting fracture healing. The resorption of the adjacent bone by the continuous pressure from tissue herniation through the bone gap adds to the progression of the fracture line.

The brain extrusion may be present shortly after diastatic linear fracture in neonates and young infants [3]. resulting in focal dilatation of the lateral ventricle near the growing fracture. This focal dilatation is reversible and may normalize after surgical repair [4]. Because cranial defects never increase if the underlying dura is intact and also craniotomy performed without watertight closure of dura does not cause a growing fracture, therefore, for growing fractures to develop a dural laceration is a must with a fracture line.

Another risk factor is severity of underlying trauma. A linear fracture associated with hemorrhagic contusion of subjacent brain suggests a trauma significant enough to cause dural laceration. The brain at the growing fracture site shows a cerebromeningeal cicatrix formation. Cystic changes at the growing fracture site may be because of cystic encephalomalacia. Post traumatic aneurysms and subdural hematomas have also been reported to accompany growing skull fractures [6],[7]. Though most patients show damage to underlying brain, this finding is not a prerequisite for the development of growing skull fractures [8].

These skull fractures after reaching maximum extent will cease to grow and remain stable through out adulthood [2],[5].

A depressed fracture usually does not become a growing fracture [9] but a linear fracture extending from a depressed one can become one [10].

A fracture with a diastasis of >4mm may be considered at risk of developing a growing skull fracture [3],[11],[12]. But a post traumatic diastasis of a cranial suture is an unusual site for a growing fracture. Growing fractures can even be seen in older individuals usually in linear fractures in thin areas of skull base associated with dural laceration, for eg. Orbital roof, ethmoid plate, frontal sinus.

These fractures commonly present as a progressive, often pulsatile, scalp mass that appears sometime after head trauma sustained during infancy. Also related are seizures, hemiparesis, psychomotor retardation, but an asymptomatic palpable mass may be the sole sign. The usual site is the parietal region. A growing fracture at the skull base may present with ocular proptosis or CSF rhinorrhea or otorrhea.

A plain radiograph may show a fracture line that crosses a coronal or lambdoid suture but it is usually limited to a parietal bone [13]. On CT a hypodense lesion is seen near the fracture site. Intracranial hypodense area may be a encephalomalacia, arachnoid loculation or cortical atrophy.

Owing to the risk of neurological deterioration and development of seizure disorder surgical correction of growing fractures is recommended.



 
   References Top

1.Des champs GT Jr, Blumenthal BI. Radiologic seminar CCXLIX: Growing skull fractures of childhood. J Miss state Med Assoc 1988; 29:16-17.  Back to cited text no. 1    
2.Ramamurthi B, Kalanaraman S. Rationale for surgery in growing fractures of skull. J. Neurosurg 1970; 32:427-430.  Back to cited text no. 2    
3.Thompson JB, Mason TH, Haines GL, Cassidy RJ. Surgical management of diastatic linear fractures in infants. J Neurosurg 1973; 39:493-497.  Back to cited text no. 3  [PUBMED]  
4.Scarfo GB, Mariottini A, Tomaccini D, Palma L. Growing skull fractures: progressive evolution of brain damage and effectiveness of surgical treatment. Childs Nerv Syst 1989; 5:163-167.  Back to cited text no. 4  [PUBMED]  
5.Rahimizadeh. A growing skull fracture in the elderly. Neurosurgery 1986; 19:675-676.  Back to cited text no. 5    
6.Buckinghum MJ, Crone KR, Ball WS, et al . Traumatic intracranial aneurysms in childhood: Two cases and review of literature. Neurosurgery 1988; 22:398-408.  Back to cited text no. 6    
7.Locatelli D, Messina AL, Bonfanti N, et al . Growing fractures: an unusual complication of head injuries in paediatric patients. Neurehirurgia (stuttg) 1989; 32:101-104.  Back to cited text no. 7    
8.Lende RA, Erickson TC, Growing skull fractures. J Neurosurg 1961; 18:479-489.  Back to cited text no. 8    
9.Arsenic C, Ciurea AV. Clinicotherapeutic aspects in growing skull fractures. A review of literature. Childs Brain 1981; 8:161-172.  Back to cited text no. 9    
10.Lye RH, Occleshaw JV, Dutton J. Growing fractures of skull and the role of CT. Case report. J Neurosurg 1981; 55:470-472.  Back to cited text no. 10    
11.Gruber FH, Post traumatic leptomeningeal cysts. Am J Roentgenology 1969; 105:305-307.  Back to cited text no. 11    
12.Traveras JM, Ransohoff J. Leptomeningeal cysts of brain following trauma with erosion of skull: a study of seven cases treated by surgery. Neurosurg 1953; 10:233-243.  Back to cited text no. 12    
13.Kingsley D, Till K, Hoase R. Growing fractures of skull. J Neurosurg psychiatry 1978; 41:312-318  Back to cited text no. 13    

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Correspondence Address:
S Khandelwal
Department of Radiodiagnosis, G.R. Medical college, Gwalior
India
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    Figures

[Figure - 1], [Figure - 2], [Figure - 3]

This article has been cited by
1 Leptomeningeal cyst: A complication of trivial head injury
Kulkarni, K.A., Pandya, N.A., Hulse, T.
Internet Journal of Pediatrics and Neonatology. 2009; 9(2)
[Pubmed]



 

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    Introduction
    Case Report
    Discussion
    References
    Article Figures

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