- Department of Neurosurgery, NIMHANS, Bengaluru, Karnataka, India
- Department of Neuro-radiology, NIMHANS, Bengaluru, Karnataka, India
Department of Neurosurgery, NIMHANS, Bengaluru, Karnataka, India
DOI:10.4103/sni.sni_431_16Copyright: © 2017 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Manish J. Mathew, Nupur Pruthi, Amey R. Savardekar, Sarbesh Tiwari, Malla B. Rao. Midline depressed skull fracture presenting with quadriplegia: A rare phenomenon. 14-Mar-2017;8:39
How to cite this URL: Manish J. Mathew, Nupur Pruthi, Amey R. Savardekar, Sarbesh Tiwari, Malla B. Rao. Midline depressed skull fracture presenting with quadriplegia: A rare phenomenon. 14-Mar-2017;8:39. Available from: http://surgicalneurologyint.com/surgicalint_articles/midline-depressed-skull-fracture-presenting-with-quadriplegia-a-rare-phenomenon/
Background:Midline depressed skull fractures (MDSFs) deserve a special mention among skull fractures and should always be treated with caution. Here, an extremely unusual clinical presentation of a case of MDSF is highlighted along with its successful surgical management.
Case Description:A 26-year-old male presented with quadriplegia following assault on the head with sharp weapons. The patient had multiple lacerated wounds on the scalp with underlying cranial fractures. On evaluation, computerized tomography (CT) of the brain showed a midline depressed skull fracture compressing the superior sagittal sinus (SSS) causing bilateral frontoparietal venous infarction. CT venogram showed a filling defect of the SSS due to the penetrating bone fragment. He underwent elevation of the depressed fracture and repair of the sinus with pericranial graft. Patient improved neurologically, and follow-up magnetic resonance venogram showed a patent SS.
Conclusion:MDSF can present with quadriparesis/quadriplegia due to middle one-third SSS obstruction/thrombosis leading to bilateral motor cortical venous infarction. Such MDSFs may require emergent surgical elevation of the depressed bone fragment for restoration of the patency of the sinus.
Keywords: Compound depressed skull fracture, midline depressed skull fracture, quadriparesis, quadriplegia, superior sagittal sinus thrombosis, surgical intervention
Depressed skull fracture is a type of traumatic brain injury often seen secondary to assault. It can lead to infection, cosmetic deformity, intracranial hematoma, or a local mass effect on underlying brain tissue, leading to neurological deficits with possibility of early or delayed seizures.[
History and clinical findings
A 26-year-old male was allegedly assaulted by multiple unknown assailants with sharp weapons (knives and sickle) on his head. At presentation, patient had a Glasgow Coma Scale (GCS) of E3M6V5. His pupils were equal, bilaterally 3 mm in diameter, and briskly reacting to light. On motor system examination, the patient had quadriplegia, with Medical Research Council (MRC) grade 0/5 power in all four limbs along with decreased tone. On sensory examination, the patient had intact crude touch, pain, and temperature sensations in all four limbs. Loss of motor function in all four limbs in conjunction with intact sensations all over the body pointed towards a cranial cause for the deficit and ruled out any spinal cord or peripheral nerve involvement. Multiple sutured lacerated wounds were observed over the scalp: Large midline vertical wound extending from occipital protuberance to forehead (~20 cm in length), transverse wound on right posterior frontal scalp (~5 cm), vertical wound on the left frontal scalp (~8 cm), and vertical wound on the left parietal scalp (~7 cm).
Investigations and management
Computerized tomography (CT) scan of the brain showed midline parietal depressed fracture with bilateral frontoparietal mixed density lesions and surrounding edema suggestive of venous infarction [Figure
(a) Computed tomography scan showing midline depressed fracture compressing the SSS and causing bilateral posterior frontal venous infarctions, (b) MRI cervical spine showing normal study, (c) CT venography (preoperative) showing a defect in the SSS, (d) Bone window of the same CT venography image as in c showing the depressed bone fragment in the midline, (e) MRV done at 6 months follow-up showing filling of the SSS, (f) MRI scan of the brain in coronal section (posterior frontal region) showing resolved venous infarctions
The patient was diagnosed to have a compound depressed skull fracture over the midline parietal bones, with the depressed bone fragment causing SSS obstruction. In view of SSS obstruction and presence of progressive venous infarction, patient underwent bilateral parietal parasagittal craniotomy, elevation of depressed fracture, repair of the tear in the SSS with pericranial graft, and repair of adjacent dural tear. Intraoperatively, after elevation of the depressed fracture, a tear was noted on the superior surface of SSS with brisk bleeding. Normal proximal and distal sinus was exposed and the defect was repaired with pericranial graft overlaid with a muscle patch. Bone fragments were discarded and thorough wash was given followed by wound closure in a single layer.
Postoperatively, patient was managed with anti-edema measures, anti-epileptics, and broad spectrum antibiotics. At discharge, he had MRC grade 2/5 power in left upper limb with MRC grade 0/5 power in all other limbs. At 6-month follow-up, patient had MRC grade 4/5 power in all four limbs. MRV imaging showed a patent SSS [
Depressed skull fractures occur due to a high energy impact on a small area of the skull leading to indentation of the affected segment.[
MDSFs with underlying SSS injury and resulting thrombosis can lead to venous hypertension or intracranial hypertension due to impairment of CSF absorption.[
Management of a midline depressed fracture can be a dilemma for neurosurgeons because of the risk of massive hemorrhage from SSS intraoperatively.[
Depressed fracture leading to monoparesis is well-known due to compression of underlying motor cortex by the depressed fragment. Patients of MDSFs presenting at a later stage with BIH have been described.[
The elevation of the depressed fracture led to flow restoration through the sinus, which was demonstrated by MRV. In our case, the the depressed bony fragment causing obstruction of the SSS was removed, which revealed a rent in the SSS extending onto the adjoining dura. We repaired the rent with a pericranial graft so that we could achieve a watertight closure of the dura. A partial or full-thickness pedicled dural graft was considered, however, the presence of tear extending onto the adjoining dura and presence of dural venous lakes in the vicinity precluded its use in our patient. Opening up of the SSS may have resulted in decrease in the size of the eventual venous infarct and could be validated by the neurological improvement seen in our patient at follow-up. Hence, radiological evidence of SSS obstruction/thrombosis in MDSF, along with corresponding neurological deficits may be considered as an indication for surgery and can help in the restoration of venous blood flow in the SSS leading to neurological improvement, as seen in our case. This surgical approach is perilous; hence, should be undertaken by experienced microneurosurgeons trained in vascular anastomotic techniques and under stringent neuroanesthesia monitoring.
MDSFs deserve a special mention among skull fractures and should always be treated with caution. Presentation of MDSF can be varied and rare presentation such as quadriparesis/plegia should be noted. An MR or CT venogram is imperative in the evaluation of MDSFs to look for SSS stenosis, obstruction, or thrombosis. Emergency surgical elevation of depressed fragment for flow restoration through the venous channel should be considered if filling defect is noted on imaging and the patient is symptomatic for the same. In lieu of good postoperative outcome, as seen in our case, surgical intervention for symptomatic midline depressed skull fracture merits consideration in the present neurosurgical era.
Disclosure: The authors report no conflict of interest.
Informed Consent: The patient and his relatives have consented to the submission of this case report to the journal.
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1. Donovan DJ. Simple depressed skull fracture causing sagittal sinus stenosis and increased intracranial pressure: Case report and review of the literature. Surg Neurol. 2005. 63: 380-3
2. Fuentes S, Metellus P, Levrier O, Adetchessi T, Dufour H, Grisoli F. Depressed skull fracture overlying the superior sagittal sinus causing benign intracranial hypertension. Description of two cases and review of the literature. Br J Neurosurg. 2005. 19: 438-42
3. LeFeuvre D, Taylor A, Peter JC. Compound depressed skull fractures involving a venous sinus. Surg Neurol. 2004. 62: 121-5
4. Meltzer H, LoSasso B, Sobo EJ. Depressed occipital skull fracture with associated sagittal sinus occlusion. J Trauma. 2000. 49: 981-
5. Miller JD, Jennett WB. Complications of depressed skull fracture. Lancet. 1968. 292: 991-5
6. Syed AA, Arshad A, Abida K, Minakshi S. Paraperesis: A rare complication after depressed skull fracture. Pan Afr Med J. 2012. 12: 106-
7. Van Den Brink WA, Pieterman H, Avezaat CJ. Sagittal sinus occlusion, caused by an overlying depressed cranial fracture, presenting with late signs and symptoms of intracranial hypertension: Case report. Neurosurgery. 1996. 38: 1044-6
8. Yokota H, Eguchi T, Nobayashi M, Nishioka T, Nishimura F, Nikaido Y. Persistent intracranial hypertension caused by superior sagittal sinus stenosis following depressed skull fracture. Case report and review of the literature. J Neurosurg. 2006. 104: 849-52