PMC8769400_01
(A, B) A CT scan showing a wide skull fracture of the right parietal bone, from the lambdoid to coronal sutures, measuring 10 cm at its superior portion and 4 mm at its inferior portion. (C) At 6 days post-injury, the fracture width had enlarged, and it was greater than 6 mm on CT scan. CT: computed tomography.
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F1
Besides confirming a cephalohematoma, computed tomography (CT) scan revealed an extensive skull fracture of the right parietal bone, from the lambdoid to coronal sutures, of roughly 10 cm and bone diastasis of 4 mm, without brain compression (Fig. 1A and 1B). We surgically treated her because the fracture width was unstable and greater than 6 mm on CT at 6 days post-injury (Fig. 1C).
Axial MRI showing the accumulation of subcutaneous fluid similar to cerebrospinal fluid, brain contusion, and herniated cortex at the right parietal lobe. (A) T1-, (B) T2-, and (C) fluid-attenuated inversion recovery-weighted images. MRI: magnetic resonance imaging.
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F2
Magnetic resonance imaging (MRI) performed 5 days after the injury detected a brain contusion and subcutaneous accumulation of fluid as dense as cerebrospinal fluid (CSF; Fig. 2).
Intraoperative photograph under visualization with an endoscope. (A) Upper row: Illustration showing the association between the edges of incision and dural laceration, and the approach with an endoscope for dural laceration (edges of incision [black arrowhead] and dural laceration [white arrowhead]). Lower row: illustration showing the duraplasty, using inlay and onlay grafts to close the dural defect. (B) The brain tissue with the contusion bulged and herniated from the dural laceration. Due to the pulsating, it compressed the fracture margin. (C) The edge of dural defect was visible (arrowhead). (D) The collagen matrix inserted in the subdural space as an inlay graft. (E) The overlapping dural defect surrounding the dural margins of the defect as an onlay graft.
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F3
The affected brain tissue bulged and herniated from the dural laceration, and it compressed the fracture margin while pulsating (Fig. 3B). There was no strict adhesion between dura mater and brain tissue and they could be separated without difficulty. Upon visualization, the edges of the dural defect did not appear to extend beyond the skull fracture (Fig. 3C). Subsequently, an onlay graft was placed over the dural defect, overlapping at the margins, and hydrated with physiological saline. (Fig. 3).
Postoperative course. A postoperative 3D CT scan showing the bonded fracture margins. (A) A photograph immediately after performing skin closure. (B) Four months after surgery, the MRI shows neither recurrence nor abnormal findings. (C) T1-, (D) T2-, and (E) fluid-attenuated inversion recovery-weighted images. CT: computed tomography, MRI: magnetic resonance imaging.
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F4
Finally, the opposite sides of the fracture margins were drawn and bonded by 3-0 nylon suture before the incision was closed (Figs. 4A and 4B). The patient was healthy, with neither neurological deficits nor recurrence of the scalp swelling, and MRI did not demonstrate abnormal findings at 4-month follow-up (Figs. 4C-4E).