Discussion:
Birth-related traumas could cause various cranial hematoma in
neonates(5). Cephalhematoma is among the most seen hematomas, but OCH is
a rare condition. According to previous reports, approximately 20
percent of cephalhematomas undergo calcification, but most resolve after
conservative follow-up (2). When found at older ages, OCH could be
mistaken for other ossified skull lesions (1). OCH can resemble a
depressed fracture that needs different management(6). The pericranium
covers the hematoma and, in older patients, causes the ossified
outlining layer to reach the external table, which could be not
distinguished with histological examinations. CIH is another rare
pathology that could be mistaken with OCH. The exact etiology is still
unknown, but the use of anticoagulants, trauma in birth, and shunt
surgeries have been previously mentioned in the literature(7). Usually,
CIH resolves spontaneously, but if it is not, a connective tissue
surrounds the hematoma and forms a (pseudo) capsule(8). On conventional
radiography and CT scan, the typical presentation of a CIH is a
well-circumscribed, expanded intra skull lesion with or without
surrounding sclerosis with varying attenuations and internal enhancing
components after contrast injection. (9) Table 1 shows the previously
reported cases of CIH in patients with confirmed histopathological
diagnosis and without coagulopathies. The critical points for
differentiating these two conditions could be obtained by a previous
history of a soft fluctuant mass just after birth(4). Imaging could be
helpful in cases where previous diagnostic hints are not available. In
OCH cases, the contour of the underlying skull remains normal, but in
CIH cases, narrowing of the inner and outer tables of the skull could be
seen(3). Preoperative imaging is vital to correct diagnosis and
treatment; MRI and CT scans are complementary, but in some cases, as in
our patient, with a history of birth trauma, the CT scan may be
diagnostic, and MRI is not mandatory.
The surgical management of these two conditions could be different. In
CIH patients, the destruction of the inner table could need a
reconstruction which can be done with cranioplasty. Still, in OCH
patients, due to the excellent contour of the underlying skull, there is
no need for cranioplasty, and an en-block excision could be obtained
with a simple craniectomy as we did in our case(1)(3). Therefore, we
suggest craniectomy with en-bloc organized hematoma removal as the
treatment of choice for OCH. High speed-drill could be used to smoothen
the borders of the underlying bone to give the skull a proper shape, as
we did in this case. On the other side, in CIH patients with the
destruction of the inner table, craniotomy followed by a cranioplasty is
a better option.