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Vascular Channel Mimicking a Skull Fracture
THE JOURNAL OF PEDIATRICS • www.jpeds.com
INSIGHTS AND IMAGES
Vascular Channel Mimicking a Skull Fracture
A
15-month-old boy was referred for magnetic resonance imaging to evaluate macrocephaly. The magnetic resonance imaging demonstrated a small subacute left parietal subdural hematoma (Figure 1, A). The medical history was significant for delivery at 32 weeks gestation, no prenatal care, prenatal illicit drug exposure, several cutaneous hemangiomas below the neck in different phases of evolution, and foster care placement since 1 month of age. Additional medical evaluation included a head computed tomography with 3-dimensional reconstruction, which identified only a right frontal bone defect interpreted as a fracture (Figure 2; available at www.jpeds.com). Because of the skull and intracranial findings without a history of trauma, an evaluation for physical abuse was completed. A skeletal survey was significant for a longitudinal irregularity within the right frontal bone (Figure 1, B). Re-evaluation of the head computed tomography clarified the skull defect as a diploic vein tracking within the bone causing the calvarial deformity (Video; available at: www.jpeds.com). Skull defects, sometimes described as pseudofractures, include variation in suture formation1 and neurovascular channels.2 Cranial suture variations have been reported as child abuse mimics.3 Enlarged diploic veins and emissary veins (collateral pathways connecting dural sinuses to the external jugular circulation) are usually normal variants and can mimic fractures in adults.2 These skull veins have not been identified as
a cause of pediatric pseudofractures or abuse mimics, to our knowledge. The American Academy of Pediatrics has published guidelines for age appropriate evaluation for occult injuries.4 Prompt identification and evaluation of sentinel injuries of abuse is important due to associated morbidity and mortality.5 Equally important is the correct identification of mimics of abuse. These complex cases need an interdisciplinary approach to help differentiate fractures from pseudofractures. Thus, vascular variants must be differentiated from skull fractures for accurate diagnosis and care. ■ Caroline L. S. George, MD Nancy S. Harper, MD Department of Pediatrics Daniel Guillaume, MD Department of Neurosurgery Zuzan Cayci, MD David Nascene, MD Department of Radiology University of Minnesota Masonic Children’s Hospital Minneapolis, Minnesota References available at www.jpeds.com
Figure 1. A, Axial fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) (subdural hematoma at arrow). B, Anterior-posterior skull radiograph (vascular channel at arrows, lambdoid suture at arrow heads).
J Pediatr 2016;■■:■■-■■ 0022-3476/$ - see front matter. © 2016 Elsevier Inc. All rights reserved. http://dx.doi.org10.1016/j.jpeds.2016.10.070
1 CRP 5.4.0 DTD ■ YMPD8775_proof ■ November 15, 2016
THE JOURNAL OF PEDIATRICS • www.jpeds.com References 1. Choudhary AK, Jha B, Boal DK, Dias M. Occipital sutures and its variations: the value of 3D-CT and how to differentiate it from fractures using 3D-CT? Surg Radiol Anat 2010;32:807-16. 2. Koesling S, Kunkel P, Schul T. Vascular anomalies, sutures and small canals of the temporal bone on axial CT. Eur J Radiol 2005;54:335-43.
Volume ■■ 3. Tharp AM, Jason DR. Anomalous parietal suture mimicking skull fracture. Am J Forensic Med Pathol 2009;30:49-51. 4. Christian CW. The evaluation of suspected child physical abuse. Pediatrics 2015;135:e1337-54. 5. Ravichandiran N, Schuh S, Bejuk M, Al-Harthy N, Shouldice M, Au H, et al. Delayed identification of pediatric abuse-related fractures. Pediatrics 2010;125:60-6.
Figure 2. A, Head computed tomography (CT) axial bone window. B, Three-dimensional reconstruction demonstrating frontal bone defect mimicking a fracture (arrows).
1.e1
George et al. CRP 5.4.0 DTD ■ YMPD8775_proof ■ November 15, 2016
INSIGHTS AND IMAGES
Vascular Channel Mimicking a Skull Fracture
A
15-month-old boy was referred for magnetic resonance imaging to evaluate macrocephaly. The magnetic resonance imaging demonstrated a small subacute left parietal subdural hematoma (Figure 1, A). The medical history was significant for delivery at 32 weeks gestation, no prenatal care, prenatal illicit drug exposure, several cutaneous hemangiomas below the neck in different phases of evolution, and foster care placement since 1 month of age. Additional medical evaluation included a head computed tomography with 3-dimensional reconstruction, which identified only a right frontal bone defect interpreted as a fracture (Figure 2; available at www.jpeds.com). Because of the skull and intracranial findings without a history of trauma, an evaluation for physical abuse was completed. A skeletal survey was significant for a longitudinal irregularity within the right frontal bone (Figure 1, B). Re-evaluation of the head computed tomography clarified the skull defect as a diploic vein tracking within the bone causing the calvarial deformity (Video; available at: www.jpeds.com). Skull defects, sometimes described as pseudofractures, include variation in suture formation1 and neurovascular channels.2 Cranial suture variations have been reported as child abuse mimics.3 Enlarged diploic veins and emissary veins (collateral pathways connecting dural sinuses to the external jugular circulation) are usually normal variants and can mimic fractures in adults.2 These skull veins have not been identified as
a cause of pediatric pseudofractures or abuse mimics, to our knowledge. The American Academy of Pediatrics has published guidelines for age appropriate evaluation for occult injuries.4 Prompt identification and evaluation of sentinel injuries of abuse is important due to associated morbidity and mortality.5 Equally important is the correct identification of mimics of abuse. These complex cases need an interdisciplinary approach to help differentiate fractures from pseudofractures. Thus, vascular variants must be differentiated from skull fractures for accurate diagnosis and care. ■ Caroline L. S. George, MD Nancy S. Harper, MD Department of Pediatrics Daniel Guillaume, MD Department of Neurosurgery Zuzan Cayci, MD David Nascene, MD Department of Radiology University of Minnesota Masonic Children’s Hospital Minneapolis, Minnesota References available at www.jpeds.com
Figure 1. A, Axial fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) (subdural hematoma at arrow). B, Anterior-posterior skull radiograph (vascular channel at arrows, lambdoid suture at arrow heads).
J Pediatr 2016;■■:■■-■■ 0022-3476/$ - see front matter. © 2016 Elsevier Inc. All rights reserved. http://dx.doi.org10.1016/j.jpeds.2016.10.070
1 CRP 5.4.0 DTD ■ YMPD8775_proof ■ November 15, 2016
THE JOURNAL OF PEDIATRICS • www.jpeds.com References 1. Choudhary AK, Jha B, Boal DK, Dias M. Occipital sutures and its variations: the value of 3D-CT and how to differentiate it from fractures using 3D-CT? Surg Radiol Anat 2010;32:807-16. 2. Koesling S, Kunkel P, Schul T. Vascular anomalies, sutures and small canals of the temporal bone on axial CT. Eur J Radiol 2005;54:335-43.
Volume ■■ 3. Tharp AM, Jason DR. Anomalous parietal suture mimicking skull fracture. Am J Forensic Med Pathol 2009;30:49-51. 4. Christian CW. The evaluation of suspected child physical abuse. Pediatrics 2015;135:e1337-54. 5. Ravichandiran N, Schuh S, Bejuk M, Al-Harthy N, Shouldice M, Au H, et al. Delayed identification of pediatric abuse-related fractures. Pediatrics 2010;125:60-6.
Figure 2. A, Head computed tomography (CT) axial bone window. B, Three-dimensional reconstruction demonstrating frontal bone defect mimicking a fracture (arrows).
1.e1
George et al. CRP 5.4.0 DTD ■ YMPD8775_proof ■ November 15, 2016