[Growing skull fracture in childhood. Presentation of 12 cases]. / Fractura evolutiva de cráneo en la infacia. Presentación de 12 casos.

Growing skull fractures (GSF) are rare complications of head injury (HI) in childhood. This entity consists of a skull fracture with an underlying dural tear that courses with a progressive enlargement of the fracture to produce a cranial defect. The pathophysiology and some aspects of its management are still controversial. In this review we present 12 patients diagnosedd and treated for a GSF at our institution between 1980 and 2002. 11 patients were under the age of 3 years and one patient was 5 years old at the moment of HI. The most common cause of injury was a fall from height. In the initial plain x-rayfilms, 11 patients showed a diastatic skull fracture and one patient only had a linear fracture. At this time, CT scan showed cortical contussion underlying the fracture in every case. The mean time between injury and presentation of GSF was 11.6 weeks. Diagnosis was made by palpation of the cranial defect and confirmed with skull x-rayfilms. The most frecuent location of GSF was in the parietal region. Associated lesions like hydrocephalus, encephalomalacia, lepto-menigeal cysts, brain tissue herniation and ipsilateral ventricular dilatation, were found in the preoperative CT or MRI. All patients underwent a dural repair with pericranium or fascia lata. The cranial defect was covered with local calvarial bone fragments in every case. Only one patient needed a cranioplasty with titanium mesh. Every child with a skull fracture must be followed until the fracture heals. Patients under the age of 3 years with a diastatic fracture and a dural tear, demostrated by TC or MRI, are more prone to develop GSF. In these cases, early repair must be adviced in order to prevent progressive brain damage.

Fractura evolutiva de cráneo en la infancia. Presentación de 12 casos / Growing skull fracture in childhood. Presentation of 12 cases

La fractura evolutiva de cráneo (FEC) es una complicación poco frecuente del traumatismo craneoencefálico (TCE) en la infancia. Consiste en una fractura con un desgarro dural subyacente, que se ensancha progresivamente hasta constituir un defecto craneal. Su fisiopatología, así como algunos aspectos del manejo terapéutico, son todavía controvertidos. Se presenta una revisión retrospectiva de 12 casos diagnosticados y tratados entre los años 1980 y 2002 en nuestra institución. Once pacientes eran menores de 3 años y uno tenía 5 años en el momento del traumatismo. La causa más frecuente de TCE fue la caída. En la radiografía inicial, 11 pacientes tenían fracturas con diastasis y solamente un paciente tenía fractura lineal. El hallazgo tomográfico común a todos los casos fue contusión cortical subyacente a la fractura. El intervalo promedio entre traumatismo y presentación de las FEC fue de 11,6 semanas. La localización preferente de las FEC fue en la región parietal. El diagnóstico se hizo por palpación de un defecto craneal y se confirmó con radiografía. Se encontraron lesiones asociadas en la TAC y RMN preoperatoria, como hidrocefalia, encefalomalacia, quistes leptomeníngeos, herniatión de tejido encefálico y dilatación ventricular ipsilateral. Todos los pacientes fueron sometidos a reparación plástica de la duramadre y el defecto craneal se cubrió con fragmentos óseos. Sólo un paciente precisó craneoplastia con malla de titanio. Todas las fracturas de cráneo en edad pediátrica deben controlarse hasta constatar su reparación. Los pacientes menores de 3 años con fracturas inicialmente diastasadas y con evidencia en la TAC o RMN de laceración dural, tienen mayor probabilidad de desarrollar una FEC. En estos casos se recomienda el tratamiento precoz para evitar un daño cerebral progresivo (AU)

Postcraniotomy gas-containing brain abscess: a neurosurgical emergency. Case report.

BACKGROUND: Gas-containing brain abscesses are very rare, and the majority are caused by Clostridium perfringens. We report a case of gas-containing brain abscess that required urgent surgery after a craniotomy for a brain tumor. METHODS AND RESULTS: The patient was a 53-year-old male who presented with a cerebral neoplasm. A temporal lobectomy was performed and the diagnosis of low grade glioma was confirmed. Although the surgery was uneventful the postoperative course was complicated; the patient became agitated and febrile and deteriorated to a deep coma. A computed tomography scan demonstrated gas in the temporal fossa at the lobectomy site, producing mass effect. Urgent surgical debridement and drainage was performed and C. perfringens and mixed flora were found. Antibiotics were started and the patient's condition markedly improved. He was awake and alert, followed commands adequately and was extubated; however, after a week he suffered massive gastrointestinal bleeding and died. CONCLUSIONS: Early recognition of a gas-containing brain abscess is of great interest to immediately start the appropriate treatment. Urgent surgical debridement and broad spectrum chemotherapy are major components in the management of this entity.