Auto-Craniotomy in Head Injury: A Rare Case Report

Abstract

Skull fractures are the well-known entity in patients with road traffic accidents (RTA) and falls from height. Skull fractures can be classified in view of site (basal or calvarial), pattern (linear, depressed, and diastasis), or type (simple or compound). Most patients commonly present with linear skull fractures. Elevated skull fractures (ESF) are a rare entity of skull fractures present in a few cases with fewer publications in literature. Most skull fractures occur due to a force acting in a perpendicular direction; however, elevated fractures occur due to force acting in a tangential direction on the calvarium. We present to you a 42-year-old male patient with a known case of psychiatric illness presented with a history of a fall from height followed by altered sensorium. On clinical evaluation and imaging, the patient has a large “skull cap” pattern of elevated calvarial fracture with a large extradural hematoma, subdural hematoma, diffuse cortical subarachnoid haemorrhage, and fronto-parietal contusion. He was operated on in emergency with a “S”-shaped incision with the removal of the fractured calvarial segment with lax duroplasty. In the post-operative period, the patient underwent tracheostomy and improved partially. He is on follow-up at present.

 

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Keywords

skull cap fracture - head trauma - traumatic brain injuries - auto craniotomy

Introduction

Skull fractures is an entity seen in patients due to trauma to the calvarium from moving objects. This is most commonly seen in road traffic accidents fall from height and assault.[1] Hitting with a heavy object like an axe or a machete can also result in a fracture of the skull bone. Skull fractures are most commonly seen in men within the age group of 20 to 40 years. Skull fractures are also seen in pediatric patients; however, they are less common as compared with adults.[2] The different patterns of skull fractures are due to the result of the force of injury perpendicular or tangential to the skull bone. Skull bone fractures can be classified as per the site as basal and calvarial. The skull fractures can be classified as per the pattern of injury (linear, depressed, and diastasis) or type (simple or compound). The most common pattern of presentation is linear bone fractures. Depressed occurs due to injury to the calvarium in a direction perpendicular to the bone.[2] This results in the displacement of the outer table of the bone below the inner table of the adjacent bony segment. The displacement can lead to injury to the dura, and entry of dirt or foreign bodies into the brain parenchyma. Vascular injury to the cortical vessels like arteries or veins or the midline sinus can also lead to excessive blood loss and shock. Exposure to foreign bodies and dirt can lead to infection in the pattern of meningitis or brain abscess (cerebritis). Cerebrospinal fluid leak, skin necrosis, and seizures are other common complications seen in depressed fractures. Elevated fractures are a separate entity; however, they can present along with depressed segments of bony fracture as well.[3]

 

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Case Report

We present you a case of a 42-year-old patient with a history of psychiatric illness who presented with a history of fall from a height of 12 feet followed by altered sensorium. He was taken to the emergency department. He was evaluated as per the Advanced Trauma Life Support guidelines. On his arrival, Glasgow Coma Scale (GCS) was low, E1V1M2. He was intubated in the emergency department due to an obstructed airway. Except for a lacerated wound over the scalp over the left parieto-occipital region, there was no other external injury. A noncontrast computed tomography (CT) brain revealed a large elevated skull fracture in a “skull cap” pattern associated with a large extradural hematoma, subdural hematoma, subarachnoid hemorrhage, and frontoparietal contusion ([Fig. 1]). CT cervical spine was normal. Ultrasound fast was found to be negative. An emergency surgery was planned. Since we needed a large calvarial exposure, an “S” pattern incision was made over the scalp including the scalp laceration ([Fig. 2]). The fractured skull segment was already elevated due to auto-craniotomy ([Fig. 3]). After stripping the dura and saving the midline sinus, the elevated calvarial segment was removed. Intraoperative findings were suggestive of a large epidural hematoma (EDH) and subdural hematoma, which was evacuated. There was extensive contusion, which was appreciated ([Fig. 4]). Sinus was preserved as such. The calvarial bone was kept in a bone bank. After hemostasis, the scalp was closed. Tracheotomy was done on day 3 postoperative due to an unpredicted outcome as initial GCS was 4. He was sent to a rehabilitation center with a GCS of E1VtrM2. He is currently on close follow-up.

Fig. 1 Noncontrast computed tomography (CT) brain showing elevated skull fracture in a “skull cap” pattern associated with a large extradural hematoma, subdural hematoma, diffuse cortical subarachnoid hemorrhage, and frontoparietal contusion.

Fig. 2 “S” pattern incision was made over the scalp.

Fig. 3 The calvarial segment was already elevated due to auto-craniotomy.

Fig. 4 Large epidural hematoma (EDH) and subdural hematoma that was evacuated.

 

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Discussion

Elevated fractures are defined when the outer table of the fractured segment is higher than the normal contour of the calvarium. The most common pattern of injury is a tangential force to a rotating head. Hitting with a heavy object like an axe can lead to a depressed segment followed by an elevation while taking out the axe in a rotational manner.[4] Contamination is found to be less in an elevated fracture as the force is tangential. Dural tears and hematoma are less common. Complications in the form of dural tears, vascular injury, and subdural hematoma and EDH are seen in elevated skull fractures, which are described in the literature. Imaging in the form of a noncontrast CT brain is needed to identify the extension of injury in the patient. CT venography can be done to rule out the sinus injury. Early evaluation and management is the key. The outcome of the patient depends upon factors like age, comorbidities, duration of trauma to arrival in emergency, pre- and intraoperative blood loss, arrival GCS, other organ system injuries, etc. The elevated fractures as an entity have been less described in world literature. Borkar et al have described a single case of elevated skull fracture in Turkish Neurosurgery in February 2009.[5] Harsh et al described 17 cases of elevated skull fracture in the Asian Journal of Neurosurgery in the year 2019 where they described the mode of injury, clinical presentation, clinicopathological findings, and treatment options highlighting the appropriate management strategies They opined that although elevated fractures are rare, issuing definite treatment protocol can reduce the morbidity and mortality of the patients.[3] To date, around 35 cases of elevated skull fractures have been reported in world literature.

 

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Highlights of the Case

• (1) “Skull cap” pattern of the elevated calvarial fracture, which is quite rare.

• (2) “S”-shaped incision used to elevate the scalp slaps for wide exposure of the entire calvarium.

• (3) Rarity of the disease with few publications describing the pattern of trauma.

 

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Conflict of Interest

None declared.

Acknowledgment

We acknowledge SOA University for the unconditional support.

• References

• 1 Gupta R, Iyengar R, Kayal A, Songara A. Elevated skull fractures: an under-recognized entity. Indian J Surg 2015; 77 (Suppl. 03) 1308-1312
• 2 Chiarelli PA, Impastato K, Gruss J, Lee A. Traumatic Skull and Facial Fractures, Principles of Neurological Surgery (Fourth Edition),2018;445–474
• 3 Harsh V, Vohra V, Kumar P, Kumar J, Sahay CB, Kumar A. Elevated skull fractures - too rare to care for, yet too common to ignore. Asian J Neurosurg 2019; 14 (01) 237-239
• 4 Kumar A, Kankane VK, Jaiswal G, Kumar P, Gupta TK. Compound elevated skull fracture presented as a new variety of fracture with inimitable entity: single institution experience of 10 cases. Asian J Neurosurg 2019; 14 (02) 410-414
• 5 Borkar SA, Sinha S, Sharma BS. Post- traumatic compound elevated fracture of skull simulating a formal craniotomy. Turk Neurosurg 2009; 19 (01) 103-105

Publication History

Article published online:
27 August 2025