posttraumatic cerebral edema leading to refractory intracranial hypertension is the main prognostic factor in brain - injured patients .
morbidity and mortality occur as a result of transtentorial herniation caused by mass effect due to cerebral swelling .
the combined medical and surgical objective during the acute phase is to prevent raised intracranial pressure ( icp ) and maintain cerebral perfusion pressure in order to limit the development of secondary lesions .
early decompressive craniotomy ( dc ) is a method for decreasing raised icp and has been associated with better outcomes . in neonates ,
as the cranial sutures are open , any associated fracture may relieve the raised icp due to craniotomy flap - elevation like effect .
an 8-day - old male child was brought to the emergency room with a history of fall from a cradle of about 3 feet height followed by loss of consciousness for half an hour .
there was no history of convulsions , vomiting or ear , nose , and throat bleed . on examination ,
the neonate was vitally stable , alert , conscious , moving all four limbs with no focal neurological deficit .
the physical examination showed a large swelling in the left temporal region behind the ear ( battle 's sign ) [ figure 1 ] .
photograph on the day of admission showing a swelling in the left temporoparietal region with battle 's sign computed tomography ( ct ) of the brain showed a large left sided frontoparietal contusion with brain herniation through the fracture segment [ figure 2 ] .
plain axial computed tomography scan brain shows a large hyperdense area in the left frontoparietal region suggestive of a contusion ( black arrow ) , as well as brain herniation , with underlying sutural widening based on the clinical examination and ct findings , a decision was taken to medically manage the patient with anti - epileptic medications and monitor for any signs of raised icp .
the child showed progressive improvement in the neurological condition and was discharged after 8 days and asked to follow - up for dural repair and cranioplasty after 3 weeks .
the child was lost to follow - up and presented 2 months later with a cystic , nonpulsatile 5 cm  4 cm swelling in the left temporal region .
ct scan showed a large cystic lesion in the left temporoparietal region with underlying bone defect [ figure 3 ] .
a diagnosis of growing fracture skull ( posttraumatic leptomeningeal cyst ) was established , and surgical intervention planned .
the neonate underwent duraplasty with pericranial graft and cranioplasty with titanium mesh plate 70 days after the head injury insult [ figure 4 ] .
the infant tolerated the procedure well and was discharged after suture removal . on 6 months
follow - up , the infant was doing well with no neurological deficits or wound - related complications .
plain axial computed tomography scan showing a large 6 cm  3.2 cm  5.3 cm cystic lesion in the left temporoparietal region with underlying bone defect in the temporal bone ( black arrow ) intraoperative photograph showing titanium mesh plate with underlying pericranial dural graft
head injury is likely to occur in children and adolescents ranging from 0 to 19 years in approximately 200 per 100,000 populations with a mortality rate of 29% , according to the national center for health statistic .
different components , such as vasogenic and cytotoxic edema and possibly cerebral vasocongestion contribute to posttraumatic brain swelling .
this brain swelling is associated with an exponential rise in the icp and eventually leads to brain herniation syndromes . in infants with open sutures ,
the relative increases in the icp and their tolerance remain unknown though there is a concern with regards to susceptibility to ischemic injury .
any fracture extending across the cranial suture in an infant can cause bony separation leading to an open cranial vault .
linear skull fracture in association with open sutures can lead to a condition wherein an effect similar to dc is achieved . in adults with a thick solid skull , the linear undisplaced fracture can not expand and therefore probably will not tolerate an increase in icp as well .
the 2012 pediatric head injury guidelines state that decompressive craniectomy with duraplasty , leaving the bone flap out , may be considered for pediatric patients with traumatic brain injuries ( tbi ) who are showing early signs of neurological deterioration or herniation .
hypothesized that early craniotomy ( within 6 h of injury ) in pediatric patients with refractory raised icp would result in better outcomes than following the historic standard of care , which reserved surgery as a final intervention in these patients .
similar studies by kan et al . demonstrated good results with an early craniotomy . in our patient , we believe that the early dc achieved by linear undisplaced fracture and sutural diastasis prevented the development of raised icp leading to quick clinical improvement .
adelson et al . has recommended the following criteria for selecting favorable patients for craniotomy in children : ( 1 ) diffuse cerebral swelling on cranial ct imaging ; ( 2 ) within 48 h of injury ; ( 3 ) no episodes of sustained icp > 40 mm hg before surgery ; ( 4 ) glasgow coma scale score > 3 at some point subsequent to injury ; ( 5 ) secondary clinical deterioration ; and ( 6 ) evolving cerebral herniation syndrome . while , our patient initially presented with diffuse cerebral swelling on ct , the infant was otherwise neurologically intact and showed no signs of raised icp .
thus , an emergency surgery was not warranted , and early dural repair was planned .
. found high rates of bone resorption following autologous bone grafting in pediatric tbi patients similar to our previous experience .
due to this and the size of the cranial defect in our patient , we performed the cranioplasty using the titanium mesh plate .
linear undisplaced fracture in neonates along with open sutures may act as a dc relieving the raised icp almost immediately .
such infants in whom there are no signs of raised intracranial tension can be managed conservatively if the decompression effect achieved is adequate .
hence , a close clinical and radiological follow - up is essential . as the effect of decompression
 decompressive craniotomy ( dc ) is used to treat intracranial hypertension associated with traumatic brain injury . 
 early dc is associated with better outcomes . 
 we present a neonate with a history of fall with computed tomography scan showing a large frontoparietal contusion and associated parietal and temporal bone fracture . 
 this acted as a spontaneous dc causing bony segment to separate due to which the edematous brain could be accommodated . despite the presence of a large contusion , the child was neurologically intact and medically managed . 
 the neonate presented with a posttraumatic leptomeningeal cyst 2 months later , which had to be repaired surgically . 
 we discuss how a linear undisplaced fracture acts as spontaneous dc and the role of early dc in improving outcomes . 