Linear undisplaced fracture of temporoparietal bone acting as spontaneous early decompressive craniotomy in a neonate.

Decompressive craniotomy (DC) is used to treat intracranial hypertension associated with traumatic brain injury. Early DC is associated with better outcomes. We present a neonate with a history of fall with computed tomography scan showing a large frontoparietal contusion and associated parietal and temporal bone fracture. This acted as a spontaneous DC causing bony segment to separate due to which the edematous brain could be accommodated. Despite the presence of a large contusion, the child was neurologically intact and medically managed. The neonate presented with a posttraumatic leptomeningeal cyst 2 months later, which had to be repaired surgically. We discuss how a linear undisplaced fracture acts as spontaneous DC and the role of early DC in improving outcomes.

Introduction

Posttraumatic cerebral edema leading to refractory intracranial hypertension is the main prognostic factor in brain-injured patients.[1] Morbidity and mortality occur as a result of transtentorial herniation caused by mass effect due to cerebral swelling.[1] The combined medical and surgical objective during the acute phase is to prevent raised intracranial pressure (ICP) and maintain cerebral perfusion pressure in order to limit the development of secondary lesions.[2] Early decompressive craniotomy (DC) is a method for decreasing raised ICP and has been associated with better outcomes.[3] In neonates, as the cranial sutures are open, any associated fracture may relieve the raised ICP due to craniotomy flap-elevation like effect.

Case Report

An 8-day-old male child was brought to the emergency room with a history of fall from a cradle of about 3 feet height followed by loss of consciousness for half an hour. The child was crying incessantly and not breastfeeding. There was no history of convulsions, vomiting or ear, nose, and throat bleed. On examination, the neonate was vitally stable, alert, conscious, moving all four limbs with no focal neurological deficit. Pupils were bilaterally equal reacting to light. The physical examination showed a large swelling in the left temporal region behind the ear (Battle's sign) [Figure 1].

Figure 1

Photograph on the day of admission showing a swelling in the left temporoparietal region with Battle's sign

Computed tomography (CT) of the brain showed a large left sided frontoparietal contusion with brain herniation through the fracture segment [Figure 2]. There was no midline shift or brainstem compression.

Figure 2

Plain axial computed tomography scan brain shows a large hyperdense area in the left frontoparietal region suggestive of a contusion (black arrow), as well as brain herniation, with underlying sutural widening

Based on the clinical examination and CT findings, a decision was taken to medically manage the patient with anti-epileptic medications and monitor for any signs of raised ICP. The child showed progressive improvement in the neurological condition and was discharged after 8 days and asked to follow-up for dural repair and cranioplasty after 3 weeks. The child was lost to follow-up and presented 2 months later with a cystic, nonpulsatile 5 cm × 4 cm swelling in the left temporal region. This swelling was progressively increasing in size. There was no seizure or developmental delay. CT scan showed a large cystic lesion in the left temporoparietal region with underlying bone defect [Figure 3]. A diagnosis of growing fracture skull (posttraumatic leptomeningeal cyst) was established, and surgical intervention planned. The neonate underwent duraplasty with pericranial graft and cranioplasty with titanium mesh plate 70 days after the head injury insult [Figure 4]. The infant tolerated the procedure well and was discharged after suture removal. On 6 months follow-up, the infant was doing well with no neurological deficits or wound-related complications.

Figure 3

Plain axial computed tomography scan showing a large 6 cm × 3.2 cm × 5.3 cm cystic lesion in the left temporoparietal region with underlying bone defect in the temporal bone (black arrow)

Figure 4

Intraoperative photograph showing titanium mesh plate with underlying pericranial dural graft

Discussion

Head injury is likely to occur in children and adolescents ranging from 0 to 19 years in approximately 200 per 100,000 populations with a mortality rate of 29%, according to the National Center for Health Statistic.[4] Different components, such as vasogenic and cytotoxic edema and possibly cerebral vasocongestion contribute to posttraumatic brain swelling.[13] This brain swelling is associated with an exponential rise in the ICP and eventually leads to brain herniation syndromes.[1]

In infants with open sutures, the relative increases in the ICP and their tolerance remain unknown though there is a concern with regards to susceptibility to ischemic injury.

Any fracture extending across the cranial suture in an infant can cause bony separation leading to an open cranial vault. Linear skull fracture in association with open sutures can lead to a condition wherein an effect similar to DC is achieved. In adults with a thick solid skull, the linear undisplaced fracture cannot expand and therefore probably will not tolerate an increase in ICP as well.

The 2012 Pediatric Head Injury Guidelines state that decompressive craniectomy with duraplasty, leaving the bone flap out, may be considered for pediatric patients with traumatic brain injuries (TBI) who are showing early signs of neurological deterioration or herniation.[5]

The timing of DC is one important prognostic factor in the outcome. Taylor et al. hypothesized that early craniotomy (within 6 h of injury) in pediatric patients with refractory raised ICP would result in better outcomes than following the historic standard of care, which reserved surgery as a final intervention in these patients.[6] Similar studies by Kan et al. demonstrated good results with an early craniotomy.[7] In our patient, we believe that the early DC achieved by linear undisplaced fracture and sutural diastasis prevented the development of raised ICP leading to quick clinical improvement.

Adelson et al. has recommended the following criteria for selecting favorable patients for craniotomy in children: (1) Diffuse cerebral swelling on cranial CT imaging; (2) within 48 h of injury; (3) no episodes of sustained ICP >40 mm Hg before surgery; (4) Glasgow Coma Scale score >3 at some point subsequent to injury; (5) secondary clinical deterioration; and (6) evolving cerebral herniation syndrome.[8] While, our patient initially presented with diffuse cerebral swelling on CT, the infant was otherwise neurologically intact and showed no signs of raised ICP. Thus, an emergency surgery was not warranted, and early dural repair was planned.

Martin et al. found high rates of bone resorption following autologous bone grafting in pediatric TBI patients similar to our previous experience.[9] Due to this and the size of the cranial defect in our patient, we performed the cranioplasty using the titanium mesh plate.

Conclusion

Linear undisplaced fracture in neonates along with open sutures may act as a DC relieving the raised ICP almost immediately. Such infants in whom there are no signs of raised intracranial tension can be managed conservatively if the decompression effect achieved is adequate. However, these patients usually need dural repair as they develop growing fracture skull. Hence, a close clinical and radiological follow-up is essential. As the effect of decompression is achieved almost immediately, these patients tend to have better outcomes.

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Conflicts of interest

There are no conflicts of interest.