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.