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Core > Pediatrics: Skull and Scalp > Flashcards

Pediatrics: Skull and Scalp Flashcards

1
Q

Craniosynostosis

A

Premature fusion of one or several of the cranial sutures, resulting in a deformed head shape

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2
Q

What are the major cranial sutures?

A
  • Sagittal (separates the bilateral parietal bones)
  • Coronal (separates frontal/parietal bones)
  • Metopic (splits the frontal bone)
  • Lambdoid (separates parietal/occpital bones)
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3
Q

What is the order of fusion of the major cranial sutures?

A
  • Metopic (within 2-3 months of life)
  • Coronal
  • Lambdoid
  • Sagittal
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4
Q

What is the most common form of craniosynostosis?

A

Sagittal, causing scaphocephaly (long, narrow head)

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5
Q

Metopic synostosis causes…

A

Trigonocephaly (triangular forehead with eyes close together and underdeveloped ethmoid sinuses)

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6
Q

Sagittal synostosis causes…

A

Scaphocephaly (long, narrow head)

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7
Q

Coronal synostosis causes…

A
  • Brachycephaly (if bilateral)
  • Harlequin eye (if unilateral)

Note: The bilateral form is more rare than the unilateral form.

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8
Q

Lambdoid synostosis causes…

A

Turricephaly (if bilateral)

Note: This is the least common cranial synostosis.

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9
Q

Complications of metric synostosis

A

Cognitive disorders (growth restriction of the frontal lobes)

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10
Q

Complications of sagittal synostosis

A

Usually asymptomatic (normal IQ. no hydrocephalus)

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11
Q

Sagittal synostosis is associated with…

A

Marfans

Note: Both are tall and skinny (scaphocephaly is a long, narrow head).

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12
Q

Plagiocephaly

A

Term used to describe flat skull

Note: Anterior plagiocephaly refers to unilateral coronal synostosis and posterior plagiocephaly refers to unilateral lambdoid synostosis. Deformational plegiocephaly is a benign positional molding of the skull not due to a pathologic process.

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13
Q

“quizzical eye” appearance…

A

Think trigonocephaly due to metric synostosis

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14
Q

“harlequin eye” appearance…

A

Think brachycephaly due to unilateral coronal synostosis

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15
Q

Positional plagiocephaly

A

Flattening of the skull due to positioning (e.g. infant sleeps on the same side every night)

Note: This is the most common cause of an abnormal skill shape in an infant.

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16
Q

How can you tell the difference between a true unilateral lambdoid craniosynostosis and positional plagiocephaly?

A

Unilateral lambdoid craniosynostosis should be present at birth and results in the ipsilateral ear moving posteriorly (towards the flat part)

Positional plagiocephaly develops weeks after birth and results in the ipsilateral ear moving anteriorly (away from the flat part)

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17
Q

If you are suspecting craniosynostosis, what test should you recommend to confirm?

A

CT with 3D recons

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18
Q

Absence/dysplasia of the greater sphenoid wing…

A

Think NF-1

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19
Q

Tibial pseudoarthrosis and scoliosis…

A

Think NF-1

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20
Q

Lateral thoracic meningocele…

A

Think NF-1

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21
Q

Bone defect in the region of the lambdoid suture OR astern defect…

A

Think NF-1

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22
Q

Clover leaf skull syndrome (AKA Kleeblattschadel)

A

Enlargement of the head with a trilobed configuration (resembling a 3-leaf clover) that results from premature synostosis of the coronal and lambdoid sutures (most commonly)

Note: The sagittal suture often also closes.

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23
Q

What is the most significant complication of Kleeblattschadel?

A

Clover leaf skull syndrome is commonly associated with hydrocephalus

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24
Q

Kleeblattschadel is associated with…

A
  • Thanatophoric dysplasia
  • Apert syndrome (severe)
  • Crouton syndrome (severe)

Note: This is also called clover leaf skull syndrome.

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25
Q

Apert’s syndrome

A
  • Brachycephaly (usually)
  • Fused fingers/toes (syndactyly, often symmetric)
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26
Q

Crouzon’s syndrome

A
  • Brachycephaly (usually)
  • Maxillary/mandibular hypoplasia
  • Hydrocephalus is common
  • Chiari I malformations (70%)
  • Associated with patent ductus arteriosus and aortic coarctation
  • Short central long bones humerus/femus (rhizomelia)

Note: Crouzon’s C’s (Coronal sutures fused, Can’t Chew, Chiari I, Coarctation, hydroCephalus, Central short bones, Crazy eyes).

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27
Q

On radiographs, you see mild skull marking that are primarily over the posterior skull…

A

Think convolutional markings (normal gyral impressions on the inner surface of the skull)

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28
Q

On radiographs, you see numerous skull markings along the posterior and anterior skull…

A

Think “copper beaten” skull due to increased intracranial pressure

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29
Q

Causes of a “copper beaten” skull…

A

Increased intracranial pressure (e.g. craniosynostosis, obstructive hydrocephalus)

Note: A “copper beaten” skull has numerous skull markings around the entire skull.

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30
Q

Oval, round, and finger-shaped defects in the skull, most prominently affecting the parietal bones…

A

Think Luckenschadel (due to defective bone matrix)

Note: This can be differentiated from a “copper beaten” skull because Luckenschadel craters aren’t pyriform and are usually present at birth.

31
Q

Luckenschadel is associated with…

A
  • Chiari II malformation
  • Neural tube defects
32
Q

What are the most important causes of lytic skull lesions in a kid?

A
  • Langerhans cell histiocytosis
  • Leptomeningeal cyst
  • Metastasis (from neuroblastoma)
33
Q

Beveled hole in the skull…

A

Think Langerhans cell histiocytosis

Note: The hole is beveled because this disease process favors the inner table.

34
Q

Button sequestrum…

A

Think Langerhans cell histiocytosis

Note: This is when there is a central island of normal bone within a lytic lesion.

35
Q

Lytic skull lesion in a kid with a history of neuroblastoma…

A

Skull metastasis

36
Q

Parietal foramina

A

Symmetric holes in the parietal bones due to delayed or incomplete ossification (benign congenital defect)

Note: These can get so large they fuse in the middle.

37
Q

Parietal foramina are associated with…

A

Cortical and venous anomalies

38
Q

Intrasutural bones at the lambdoid sutures…

A

Wormian bones

Note: If there are more than 10 think about syndromes (e.g. osteogenesis imperfecta)

39
Q

Greater than 10 worming bones and absent clavicle…

A

Cleidocranial dysostosis

40
Q

What is the differential for worming bones (other than idiopathic)?

A

PORK-CHOP

  • Pyknodysostosis
  • Osteogenesis imperfecta
  • Rickets
  • Kinky hair syndrome
  • Cleidocranial dysostosis
  • Hypothyroidism/hypophosphatemia
  • One too many chromosomes (Downs)
  • Primary Acro-osteolysis (Had-Cheney)
41
Q

25 y/o with expansile, benign-appearing lytic lesion in the skull…

A

Think dermoid/epidermoid of the skull

42
Q

What is the difference between a dermoid and an epidermoid?

A

Epidermoid only contain squamous epithelium

Dermoids contain squamous epithelium and other things (hair follicles, sweat glands, etc.)

43
Q

Which usually presents earlier: dermoid or epidermoid?

A

Dermoid

Note: Epidermoids usually appear at age 20-40.

44
Q

Most common location for dermoid/epidermoid?

A
  • Parietal regions (epidermoid)
  • Midline (dermoid)
45
Q

Midline dermoids are associated with..

A

Encephaloceles

46
Q

How can you differentiate dermoids from epidermoids on CT?

A

Epidermoid should be CSF density

Dermoids should be more dense and more heterogeneous +/- calcifications

47
Q

What are the 3 scalp hematoma types?

A
  • Subgaleal hemorrhage (deep to galea)
  • Cephalohematoma (deep to periosteum)
  • Caput seccedaneum (superficial to galea, in the skin)
48
Q

Which scalp hematoma type is limited by suture lines?

A

Cephalohematoma (this is deep to the periosteum)

49
Q

Scalp hematoma with a calcified outer border that can leave a deformity similar to myositis ossificans…

A

Cephalohematoma

50
Q

Which scalp hematoma type is potentially life threatening?

A

Subgaleal hemorrhage (can cover a very large area, leading to rapid blood loss)

51
Q

Treatment for cephalohematoma

A
  • Usually requires no intervention
  • Drainage if superinfected (most often E. coli)
52
Q

Treatment for caput succedaneum

A

Requires no intervention

53
Q

Subgaleal hemorrhage in a newborn is usually caused by…

A

Vacuum extraction

54
Q

Cephalohematoma in a newborn is usually caused by…

A

Instrument or vacuum extraction

55
Q

Caput succedaneum in a newborn is usually caused by…

A

Prolonged delivery

56
Q

What is the most common cause of morbidity and mortality in young children?

A

Head trauma (accidental and non-accidental)

57
Q

Diastatic fracture

A

A fracture involving a skull suture (most commonly the lambdoid suture)

Note: If it is along the suture line, it may just appear as asymmetric suture widening.

58
Q

Depressed skull fracture

A

A skull fracture that is depressed inwards by at least the thickness of the skull

Note: Called “compound” if there is also a scalp laceration and “penetrating” if there is also a dural tear.

59
Q

Ping pong fracture

A

A type of depressed skull fracture where there is no cortical break (greenstick/buckle fracture), resulting in an indentation of the skull, similar to how a ping pong ball can get dented

Note: This often occurs in the setting of birth trauma (e.g. forceps).

60
Q

Prognosis of ping pong fracture

A

Good (much better than other depressed skull fractures, which have high morbidity)

61
Q

Indications for surgical correction of a depressed skull fracture

A
  • Fragment depression >5 mm (high risk of dural tear)
  • Epidural bleed
  • Superinfection (abscess/osteomyelitis)
  • Cosmetic reasons
  • If frontal sinus is involved (may need to obliterate the frontal sinus to prevent mucocele formation)
62
Q

Leptomeningeal cyst

A

When leptomeninges herniate through the torn dura from a skull fracture, leading to progressive widening of the fracture site and preventing it from healing

63
Q

Kid has a skull fracture that was not surgically corrected and over the following few months appears to be getting larger rather than healing…

A

Think leptomeningeal cyst (due to leptomeninges herniating through a dural tear, preventing healing)

64
Q

Sinus pericranii

A

A rare disorder that can be shown as a focal skull defect with an associated vascular malformation (the low flow vascular malformation is what causes the focal skull defect)

65
Q

Focal skull defect makes you think sinus pericranii, what is the next step?

A

Ultrasound or MRI (to demonstrate the underlying vascular malformation)

66
Q

What is the underlying pathology in sinus pericranii?

A

Vascular malformation (a communication between a dural venous sinus and an extra cranial venous structure via the emissary veins)

Note: Usually involving the superior sagittal sinus.

67
Q

Infant with skull fractures because he “fell off his bike”…

A

Think non accidental trauma (inconsistent history: infants can’t ride bikes)

68
Q

Infant with subdural hematoma…

A

Think non accidental trauma

Note: Subdural hematomas have a higher association with non accidental trauma than epidural hematomas, possibly due to vigorous shaking tearing bridging veins.

69
Q

Infant with retinal hemorrhages…

A

Think non accidental trauma

70
Q

“look high, look low” for non accidental trauma

A

Look high: Thromboses (hyper dense) cortical vein at the vertex

Look low: Retroclival hematoma (thin hyper dense sliver in the pre-pontine region)

Look lower: Edema in the cervical soft tissues

71
Q

How can you tell whether a retroclival hematoma is epidural or subdural?

A

Retroclival hematomas above the tectorial membrane are subdural

Retroclival hematomas below the tectorial membrane are epidural

72
Q

Extra axial fluid collection with medial displacement of a bridging vein…

A

Think chronic subdural hematoma

73
Q

Extra axial fluid collection with cortical veins subjacent to the inner table of the skull (normal position)…

A

Think prominent CSF spaces

Note: These are usually symmetric.

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