A Review of Techniques Used in the Management of Growing Skull Fractures.

BACKGROUND: Growing skull fractures (GSFs) are rare complications of pediatric head trauma that comprise skull fractures associated with an underlying dural tear and an intact arachnoid membrane. They are often misdiagnosed, and delay in management can lead to progression of the disease along with its neurological sequelae. Multiple clinical reports and qualitative reviews on this entity exist. To our knowledge, this represents the largest clinical review reporting on established techniques in the management of these fractures. METHODS: A literature search was performed on the databases Embase, Medline, Cochrane, and PubMed from their inception until February 2015 using the terms "Growing," "Skull," "Fracture," and their equivalent terms. Studies included were case series with 5 or more patients describing GSFs and their management. RESULTS: Twenty-two articles reporting 440 patients were included in the analysis. The mean age at trauma was 8.8 months, with the mean at presentation of 21.9 months and 57.8% of the patients being males. Most commonly, a combined dura-cranioplasty was done in 61.6% of the patients. A range of autoplastic and alloplastic materials were used in both of these techniques. Improvement from preoperative clinical status in seizures and neurological deficits was noted in 18 (12.7%) and 11 (7.05%) of the patients, respectively, following operative repair and medical management. DISCUSSION: Early recognition is crucial in the management and treatment of GSF. Children at risk for developing GSF should be monitored clinically for up to 3 months following the initial insult. The surgical treatment depends on the size of the fracture and the age of the patient. A summary of the presentation, management, associated outcomes, complications, and recommendations discussed in the literature are reported within.

Early venous thromboembolic event prophylaxis in traumatic brain injury with low-molecular-weight heparin: risks and benefits.

Traumatic brain injury (TBI) patients are known to be at high risk for venous thromboembolic events (VTEs). The Brain Trauma Foundation Guidelines (2007) state that low-molecular-weight heparin or unfractionated heparin should be used to prevent VTE complications, but suggest that there is an increased risk of expansion of intracranial hemorrhages (ICH) with VTE prophylaxis. In addition, it is unclear which treatment regimen (i.e., medication, dose, and timing) provides the best risk:benefit ratio in TBI patients. We reviewed all moderate-to-severe TBI patients admitted over a 5-year period to: (1) examine the occurrence of VTEs and their timing; (2) examine the symptomatic expansion of ICH while on VTE prophylaxis; and (3) compare the efficacy of two prophylactic agents: enoxaparin and dalteparin. Two-hundred eighty-seven patients were included. VTE prophylaxis was started 48-72 h post-trauma in all individuals who had no confounding coagulopathy, when two consecutive computed tomography (CT) scans revealed hemorrhage stability. VTEs occurred in 7.3% of treated patients, mostly within 2 weeks after trauma. Proximal VTEs occurred in 3.1% of treated patients. No significant difference in VTE rates was seen between enoxaparin (7.0%) and dalteparin (7.5%; p = 0.868). Moreover, the group treated with dalteparin was more severely injured (higher Injury Severity Score [p = 0.002]), had lower Glasgow Coma Scale (GCS) scores (p = 0.003), and had more inferior vena cava (IVC) filters placed (p = 0.007). The two groups did not show significant differences in the development of VTE when controlled for ISS and IVC filters (p = 0.819). Importantly, only one patient suffered a symptomatic expansion of ICH while on VTE prophylaxis, at 15 days post-trauma. These results suggest that current regimens of VTE prophylaxis used in our TBI population provide a relatively high level of protection against VTEs, and an extremely low risk of expanding ICH. They also suggest that there was no difference in VTE between dalteparin- and enoxaparin-treated patients.