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Pathogenesis and treatment of growing skull fractures
M G Muhonen1, J G Piper, A H Menezes
1Division of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City 52242, USA.
Insights
Growing skull fractures in children are often caused by physiological growth and cerebrospinal fluid (CSF) pulsations, leading to brain herniation. Surgical repair is effective with no recurrences observed.
Area of Science:
- Pediatric neurosurgery
- Pediatric neurology
- Pediatric trauma
Background:
- Growing skull fractures are a poorly understood complication of pediatric skull fractures.
- These fractures often occur in infants and young children.
- Etiologies include falls, motor vehicle accidents, and child abuse.
Purpose of the Study:
- To investigate the characteristics and outcomes of pediatric growing skull fractures.
- To identify the underlying causes of fracture enlargement.
- To evaluate the effectiveness of surgical management.
Main Methods:
- Retrospective review of 10 pediatric patients with growing skull fractures (1980-1993).
- Analysis of patient demographics, injury etiology, and diagnostic imaging (MRI).
- Review of surgical interventions including craniotomy, dural repair, and cranioplasty.
Main Results:
- Nine of ten patients were under one year of age at the time of injury.
- Magnetic resonance imaging (MRI) revealed various degrees of brain and/or leptomeningeal cyst herniation.
- All patients had underlying malacic cortex, but no intracranial hypertension was observed.
- Surgical repair resulted in no complications or recurrences.
Conclusions:
- Brain/leptomeningeal cyst herniation through a dural rent causes fracture enlargement.
- Physiological growth and cerebrospinal fluid (CSF) pulsations are implicated in the pathogenesis.
- Surgical intervention is a safe and effective treatment for growing skull fractures.
Background:
Growing skull fractures are poorly understood complications of pediatric skull fractures.
Methods:
A retrospective review of skull fractures at our institution from 1980-1993 revealed 10 patients with growing skull fractures. The age at injury ranged from 1-144 months, with 9 of 10 patients being under one year of age. The etiology of these fractures included falls, motor vehicle accidents, and child abuse. On average, growth of the fracture was diagnosed 14 months after the initial injury.
Results:
Six patients have had magnetic resonance imaging (MRI) with one demonstrating leptomeningeal cyst herniation, two having brain herniation, and three having both brain parenchyma and leptomeningeal cyst herniation. All patients had malacic cortex underlying the fracture, but there was no evidence of intracranial hypertension. Nine patients have undergone craniotomy with excision of granulation tissue and gliotic brain, dural repair, and cranioplasty using surrounding normal skull. There were no surgical complications or recurrences.
Conclusions:
Brain/leptomeningeal cyst herniation through a dural rent, without MRI evidence of increased intracranial pressure, implicates physiologic growth and brain cerebrospinal fluid (CSF) pulsations as the cause of fracture enlargement.