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NEUROIMAGES
Year : 2016  |  Volume : 64  |  Issue : 3  |  Page : 574-575

Posttraumatic ventriculosubgaleal fistula with underlying hydrocephalus


Department of Neurosurgery, PGIMER, Chandigarh, India

Date of Web Publication3-May-2016

Correspondence Address:
Dr. Ashish Aggarwal
Department of Neurosurgery, PGIMER, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.181581

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How to cite this article:
Aggarwal A, Gupta A, Salunke P, Dhandapani S S. Posttraumatic ventriculosubgaleal fistula with underlying hydrocephalus. Neurol India 2016;64:574-5

How to cite this URL:
Aggarwal A, Gupta A, Salunke P, Dhandapani S S. Posttraumatic ventriculosubgaleal fistula with underlying hydrocephalus. Neurol India [serial online] 2016 [cited 2019 Feb 16];64:574-5. Available from: http://www.neurologyindia.com/text.asp?2016/64/3/574/181581


A 10-year-old male patient sustained head trauma after a fall from height. His presenting Glasgow Coma Scale (GCS) was E2V2M5. His pupils were bilaterally equal and reacting. Right sixth nerve palsy was present. Local examination revealed a scalp hematoma in the right parietal region. It was a closed head injury with no external injury. Noncontrast computed tomography (NCCT) head showed a fracture in the right parietal region with underlying contusion and intraventricular hemorrhage [Figure 1]a and [Figure 1]b. The child was managed conservatively and was discharged on day 7 with his Glasgow Coma Scale (GCS) score being E4V4M6. He presented 3 weeks after discharge with a large head which was further progressively increasing. Further probing brought out the presence of the recent history of raised intracranial pressure (ICP). Examination revealed a tense fluid collection in the scalp giving the shape of tower like head [Figure 1]c. His GCS was E4V4M6. NCCT revealed hydrocephalus [Figure 1]d. X-ray skull lateral view showed a linear fracture in the right frontal and parietal region [Figure 1]e. Subsequent magnetic resonance imaging [Figure 1]f and [Figure 1]g revealed a fluid collection in the scalp layers. An interesting finding was the presence of a fistula (at the site of skull fracture) between the ventricular system and the scalp [Figure 1]f, shown by an arrow]. The patient underwent a ventriculoperitoneal shunt on the left side. Subsequent NCCT head showed decompressed ventricles [Figure 1]h. Bone window computed tomography (CT) at this stage clearly showed the skull defect with probable early everted margins [Figure 1]i. The child's tower like head gradually settled [Figure 1]j.
Figure 1: (a and b) Noncontrast computed tomography head showing a fracture in the right parietal region, underlying contusion and intraventricular hemorrhage. (c) Patient with the tense fluid collection in the scalp giving a shape of tower like head. (d) Noncontrast computed tomography head showing hydrocephalus. (e) X-ray skull lateral view showing the fracture. (f) Magnetic resonance imaging T2WI axial view and (g) and, T1W parasagittal view showing the fluid collection in scalp layers. Fistula is shown by an arrow. (h) Postshunt decompressed ventricles. (i) Computed tomography bone window showing the skull defect (j) The patient showing regression of scalp swelling

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Various authors have described posttraumatic intradiploic pseudomeningocele [1],[2],[3] and the treatment described has been the repair of the dural defect. We did not find a similar case as ours in our search of the literature. In the present case, there was underlying posttraumatic hydrocephalus. This hydrocephalus could be due to intraventricular hemorrhage. The hydrocephalus had not presented as raised ICP for a considerably long period of time because at the point of bony trauma, there was a fistulous communication between the ventricular system and the scalp layers. The fistulous tract was as a result of the combined result of bone fracture, dural defect, underlying post contusion gliotic brain and its communication with the ventricular system. Cerebrospinal fluid egressed from this fistula and got accumulated in the sub-galeal plane. This acted as a vent, preventing raised ICP inside the skull cavity. Once the CT scan showed hydrocephalus, we chose to decompress the ventricular system in the hope that once this is taken care of, the dural defect would heal spontaneously. In the past, literature also recommends shunt surgery in the situation where growing skull fracture is associated with hydrocephalus.[4],[5] Our decision against primarily going in for dural repair was based on the assumption that in the presence of high pressure, no form of dural repair will hold on and may lead to failure of the repair.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Mahapatra AK, Tandon PN. Post-traumatic intradiploic pseudomeningocele in children. Acta Neurochir (Wien) 1989;100:120-6.  Back to cited text no. 1
    
2.
Jaiswal M, Gandhi A, Sharma A, Mittal RS. Occipital post-traumatic intradiploic arachnoid cyst converted to pseudomeningocele after re-trauma: A rare complication of rare pathology. Pediatr Neurosurg 2015;50:53-5.  Back to cited text no. 2
    
3.
Agrawal D, Mishra S. Post-traumatic intradiploic pseudomeningocele. Indian Pediatr 2010;47:271-3.  Back to cited text no. 3
    
4.
Sharma RR, Chandy MJ. Shunt surgery in growing skull fractures: Report of two cases. Br J Neurosurg 1991;5:93-8.  Back to cited text no. 4
    
5.
Muthukumar N. Growing skull fracture: Two rare causes. Childs Nerv Syst 2014;30:971-5.  Back to cited text no. 5
    


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