calcified cephalohematoma: classification, indications for...

Calcified Cephalohematoma: Classification,Indications for Surgery and TechniquesChin-Ho Wong, MBBS, MRCS,* Chee-Liam Foo, MBBS, FRCS,* Wan-Tiew Seow, MBBS, FRCS1

Singapore

While calcified cephalohematoma is eminentlycorrectable, a clear description of indications forsurgery and surgical techniques are currently lack-ing in the literature. In this paper we propose asimple classification and an algorithm for themanagement of cephalohematomas. Three patientswere treated for large calcified parietal cephalohe-matomas. Craniectomy and cranioplasty were per-formed with excellent outcome. Cranioplasty wasperformed with the cap radial craniectomy tech-nique in two patients and the flip-over bull’s-eyetechnique in one patient. The literature wasreviewed on this entity and an algorithm based onthe timing of presentation, extent of calcificationand type of calcified cephalohematoma is proposed.Aspiration and compressive dressings can be usedfor early, incompletely calcified cephalohematomas.Calcified cephalohematoma causing significant dis-tortion of the calvarium requires surgical correctionand is classified as Types 1 or 2 depending on thecontour of the inner lamella. Type 1, with a normalcontoured inner lamella, can be corrected by ostec-tomy of the outer lamella. Type 2 calcified cephalo-hematoma has a depressed inner lamella. Elevation ofthe inner lamella is necessary and the cap radialcraniectomy technique can be used. We describe anovel technique, the flip-over bull’s-eye techniquesas an alternative technique for Type 2 lesions inselected patients. In conclusion, calcified cephalohe-matomas can safely be treated surgically withexcellent outcome. It is hoped that this algorithmwill serve as a useful and logical guide in decisionmaking for the management of this condition.

Key Words: Bull’s-eye, calcified, ossified, cephalohe-matoma, classification, techniques, outcome, com-

puted tomography, magnetic resonance imaging,investigation, birth trauma

Cephalohematomais a collection of bloodbetween the skull and the pericraniumconfined within the borders of cranialsutures. These hematomas, also known as

tumor cranii sanguineus,1 are often caused bytrauma associated with instrument assisted vaginalbirth and are usually apparent within 24Y72 hoursafter birth. The majority of cephalohematomasspontaneously resorb within one month of life.2

Beyond this time, calcification of the hematomaoccurs as bone is deposited under the lifted pericra-nium.3 While the exact incidence is not known, largecalcified cephalohematoma is rarely reported in theliterature.2,4,5 This is reflected in the dearth ofinformation on the surgical correction of this problem.Technique for cranioplasty was first described byKaufman et al.6 Subsequently, Chung et al7 reportedthree cases of surgically treated calcified cephalohe-matoma using technique similar to that described byKaufman. To date, the indications for surgery andtechniques for reconstruction have not been clearlyelucidated. Here we present our experience with themanagement of this entity and detail our approachand reconstructive techniques used.

ANATOMY AND CLASSIFICATION OF THE

CALCIFIED CEPHALOHEMATOMA

Calcified cephalohematoma has inner and outerlayers of bone. The inner layer consists of the fetal

inner and outer table of intramembranous calvarialbone and the outer layer is made up of subpericranialbone formed after separation of the pericranium forthe underlying calvarium. For the purpose of descrip-tion and to avoid confusion, in this article the former isreferred to as the inner lamella and the latter as theouter lamella. We classified calcified cephalohema-toma into two types; Types 1 and 2, with thedistinguishing feature being the contour of the innerlamella in relation to the surrounding normal cranialvault. Type 1 calcified cephalohematoma has a non-depressed inner lamella with no encroachment into

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From the *Department of Plastic and Reconstructive Surgery,and 1Division of Neurosurgery, KK Women’s and Children’sHospital, Singapore.

Address correspondence and reprint requests to Dr. Chin-HoWong, Department of Plastic and Reconstructive Surgery, KKWomen’s and Children’s Hospital, 100 Bukit Timah Road,Singapore 229899, Singapore; E-mail: [email protected]

the cranial vault space while in Type 2, the innerlamella is depressed into the cranial vault space (Fig1). This classification is important as it determines theappropriate corrective technique and will be dis-cussed later in this article.

METHODS AND MATERIALS

Three patients were treated at our institutionfor large calcified cephalohematomas between

January, 1998 and December, 2005. Their ages atoperative correction were four months, one year, andthree years and six months, respectively. The dimen-sions and locations of the lesion were as shown inTable 1. Indications for surgery were the unacceptablecosmetic deformity and significant distortion andencroachment into the cranial vault space (Type 2calcified cephalohematoma) in all three patients. All

three patients underwent skull roentgenogram andcomputed tomography (CT) scan prior to surgery aspart of their preoperative work-up. Operations wereperformed by a team comprising plastic andneurosurgeons.

Surgical Technique

Surgical techniques described here are for correctionof Type 2 calcified cephalohematomas, where theinner lamella is depressed into the cranial vault. A U-shaped scalp flap based inferiorly on the superficialtemporal vessels is raised. The flap is planned 1 cmbeyond the palpable elevated margin of the cephalo-hematoma. The flap is raised at the subgaleal planefollowed by reflection of the pericranial flap. The areaof excision is planned 1 cm beyond the apparentmargins of the calcified cephalohematoma. This is toensure complete removal of the affected calvarium.

Fig 1 Calcified cephalohematomas wereclassified as Type 1 or Type 2. Type 1 cal-cified cephalohematoma has a non-depressedinner lamella with no encroachment into thecranial vault space (arrows). Type 2 has aninner lamella that is depressed into the cranialvault space (arrows).

Table 1. Summary of the Age, Size and Location of Calcified Cephalohematomas, Techniques Usedand Outcomes of Our Three Patients

Case

No Age at Operation

Associate

Anomalies

Precipitating

Cause

Size and Location of the

Calcified Cephalohematoma Surgical Technique Outcome

1 1 y Nil Forceps-assisted

vaginal delivery

Left parietal, 5 x 6 cm Cap radial craniectomy technique 6 y, Excellent

2 3 y-6 mo Nil Nil Right parietal, 7 x 6 cm Flip-over bull_s-eye technique 6 mo, Excellent

3 4 mo Nil Vacuum-assisted

vaginal delivery

Right parietal, 7 x 7 cm Cap radial craniectomy technique 2 y, Excellent

CALCIFIED CEPHALOHEMATOMA: INDICATIONS FOR SURGERY AND TECHNIQUES / Wong et al

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The lesion is excised with a high-speed burr andgently lifted of the meninges. Bleeding from menin-geal vessels may be encountered and these can becontrolled with bipolar cautery.

Cranioplasty Techniques for Type 2 CalcifiedCephalohematoma of the Skull

Flip-over Bull’s-eye Technique (Reversed InnerLamella to Outer Lamella Technique)

The calcified cephalohematoma is opened with ahigh-speed drill and its content excised for histolo-gy. The elevated, deformed outer lamella is dis-carded and the depressed inner lamella is cutaround its edges, reversed (flipped-over) and platedonto the non-affected area of the calvarium, givingan impression of a ‘‘bull’s-eye.’’ The inner menin-geal surface of the inner lamella is thus re-orientatedto face the outside. The convex inner lamellaapproximates the convexity of the calvarium and

when reversed gives excellent restoration of normalcontour (Fig 2).

Cap Radial Craniectomy Technique

The cephalohematoma is excised with a high speeddrill, opened and its contents debrided. The innerlamella is discarded. Radial cuts are made on the outerlamella cap to collapse the elevated dome. Thesetriangular fragments are trimmed as necessary to fitthe defect and plated with mini-plates to re-create thegentle three-dimensional curvature of the normalskull. Irregular areas can be burred away whileexcessively large gaps can be filled with bone chipsharvested from the excess bone fragments (Fig 3).

The reconstructed calvarium is then securedback onto the skull with mini-plates. Care is taken toensure complete coverage of the reconstructedcalvarial bone graft with the pericranial flap. Meticu-lous hemostasis is ensured and the wounds closed inlayers. Drains are placed and the patient is given a

Fig 2 Schematic illustration of the flip-over bull’s-eyetechnique.

Fig 3 Schematic illustration of the cap radial craniectomytechnique.

THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 17, NUMBER 5 September 2006

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firm compression head bandage for 24 hours afteroperation.

RESULTS

A ll three patients had Type 2 calcified cephalo-hematoma. Cranioplasty was done with the cap

radial craniectomy technique in two patients andwith the flip-over bull’s-eye technique in one patient.The mean follow-up was 34 months. There were nopostoperative complications and the patients weredischarged between the third to the fifth postoper-ative day. All three had excellent contour res-toration (Table 1).

Fig 4 (A) A large parietal calcified cephalohematoma. (B) Roentgenogram (above) and CT scan (below) of the skullshowing a type 2 calcified cephalohematoma. (C) The cephalohematoma was excised and opened, revealing an organizedhematoma within its core. (D) Radial cuts were made on the outer lamella and the dome contoured to recreate the gentlecurvature of the normal calvarium. (E) The patient at six-year follow-up.


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CLINICAL REPORTS

Patient 1

A1-year-old boy presented with a 5 � 6 cm bonylesion in the left parietal region (Fig 4A). The

child was delivered vaginally at 40 weeks gestation.At birth, bilateral cephalohematoma was noted. Theright cephalohematoma resolved by one month of agewhile the left persisted and gradually hardened. Thechild was otherwise healthy. A skull roentgenogramand CT scan demonstrated features consistent witha calcified cephalohematoma (Fig 4B). Surgicalexcision was performed. The lesion measured 6 �6 cm in diameter and 3 cm in thickness (Fig 4C). Anorganized hematoma was seen upon opening thelesion and its contents sent for histology. The outerlamella was used for cranioplasty using the cap radialcraniectomy technique and secured with mini-platesand screws (Fig 4D). The reconstructed calvarium wascompletely covered by the pericranial flap and thewound closed in layers and compressive head dres-sings applied. Postoperative recovery was uneventfuland he was discharged on the fifth postoperative day.Histology showed a dense fibrous membrane withfibrous granulation tissue and hemosiderin containingmacrophages, confirming the diagnosis of cephalohe-matoma. He was well at six-year follow-up withexcellent contour of the scalp (Fig 4E).

Patient 2

A three-year, six-month-old girl presented with ahard right parietal swelling (Fig 5A). The swellingwas present since birth, firm initially with gradualhardening. It has been static in size for the past threeyears. She was the mother’s third-born and wasdelivered vaginally at 39 weeks gestation. She wasotherwise healthy with normal developmental mile-stones. The preoperative CT scan was studied andthe inner lamella was noted to have a thicknesscomparable to the normal skull and its contour wasin the mirror image of the ideal skull contour. Theflip-over bull’s-eye technique was thus conceived(Fig 5B). At operation the lesion was excised and itsdimensions were 7 � 6 cm in diameter and 3 cm inthickness. Cranioplasty was performed with the flip-over bull’s-eye technique as planned with excellentcontour restoration. The reconstructed calvariumwas completely covered by the pericranial flap andthe wound closed in layers and compressive headdressings applied (Fig 5CYG). Histological featureswere consistent with that of a cephalohematoma. Shewas discharged on the third postoperative day andwas well at six-month follow-up (Fig 5H, I).

DISCUSSION

Cephalohematoma results from trauma duringchild birth which lifts the scalp including the

pericranium off the skull bone, tearing delicate vesselsthat traverse through the bone into the scalp. Theincidence of cephalohematoma has been reported torange from 0.2Y3% of all birth.3,8,9 In a series of 126patients, Ingram and Hamilton8 noted the mostcommon site of involvement was the parietal bone(88%). The remaining 12% involved the occipitalbone. The majority of cephalohematomas spontane-ously resorb by one month of age.1Y3,10 In caseswhere the hematoma failed to resorb, progressivesubpericranial osteogenesis results in a calcifiedcephalohematoma. The incidence of calcification ofcephalohematoma has been reported to occur in3Y5% of all cephalohematomas.11 If sufficiently large,the hematoma can depress the pliable neonatalskull, causing it to encroach into the cranial vaultspace as the cephalohematoma expands.

Table 2 gives a summary of the causative andpredisposing factors, associations, differential diagno-ses and complications of cephalohematomas.3,6,8,10,12Y16

A history of a mass present since birth that is initiallyfirm and fluctuant that gradually hardens is typical ofcalcifying cephalohematoma.2 Factors that predisposesto the development of cephalohematoma, such asprolonged, difficult delivery and assisted vaginaldelivery, may also be elicited but is not a prerequisitefor diagnosis.

Imaging is the main investigation needed forcalcifying cephalohematoma. Skull roentgenogramand computed tomography (CT) scan are importantto exclude other differential diagnoses17Y19 and foroperative planning in the selection of appropriatereconstructive technique. Skull roentgenogram fea-tures includes an expansile lesion surrounded by aradio-opaque rim. There may be a variable thinning ofthe underlying calvarium. CT is the definitive stan-dard for assessment of calcified cephalohematomas.CT features include a uniformly homogenous, hypo-dense, non-enhancing core encased by bone. CT scanfeatures that should be noted in the selection oftechnique for reconstruction include: 1) the type ofcalcified cephalohematoma, i.e., Type 1 versus Type 2;2) the thickness of the inner and outer lamellascompared with the normal calvarium; and 3) thecontour of the inner lamella. For Type 2 calcifiedcephalohematoma where cranioplasty is needed, thechoice of technique is dependent on points 2 and 3. Theflip-over bull’s-eye technique is suitable only for select-ed patients. The inner lamellar should be of sufficientthickness and its contour should be approximated the


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Fig 5 (A) A large calcified cephalohematoma. (B) Preoperative CT scan. (C) The scalp flap was raised at the subgalealplane and the pericranial flap raised separately (arrow). (D) Type 2 calcified cephalohematoma with the inner lamellaencroaching into the cranial vault space (arrow). (E) The calcified cephalohematoma was opened, revealing an organizedclot within its core. (F) The inner lamella was excised, flipped-over to reconstruct the calvarium. The meningeal surface ofthe inner lamella now faced the outside. (G) The reconstructed calvarium is plated back onto the skull, resembling a bull’s-eye. (H) The reconstructed calvarium is completely covered by the pericranial flap. (I) Postoperative results with excellentcontour restoration. (J) Postoperative skull roentgenogram of the flip-over bull’s-eye technique.


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mirror image of the ideal skull contour (Fig 6). Forirregularly shaped calcified cephalohematomaswith a thinned-out inner lamella, the cap radialcraniectomy technique would be appropriate as itallows total reshaping of the outer lamella to thedesired contour.

If performed, magnetic resonance imaging(MRI) will show a bright (high) signal on the T1-weighted image and on the T2 images demonstrate apredominantly high signal with mild heterogeneity.This is characteristic for the presence of methemo-globin and indicates that the lesion was secondary tohemorrhage rather than an intra-osseus tumor.17Y19

The diagnosis will be evident at operation when thelesion is opened, revealing an organized hematomawithin its core. Histological examination should bedone as the final confirmation.

Figure 7 shows our suggested algorithm for themanagement of cephalohematoma. As majority ofcephalohematomas resorb within a month of birth,they should be expectantly observed during thisperiod. Aspiration can be attempted for any signifi-cantly sized cephalohematoma when it failed toresolved after a month. Early authors such as Cushinghave cautioned against aspiration for fear of infectionand consequently osteomyelitis.2,3 This fear is probablyunfounded with proper technique and prophylacticantibiotics available today.1,8,12 This should be doneearly (before 3Y6 months of age) before a significantamount of bone has been laid down by the liftedpericranium. It should be stated however that the rateof sub-pericranium osteogenesis seemed to vary frompatient to patient. Firlik and Adelsen20 reported a caseof large chronic cephalohematoma that was observedfor three months without any calcification and wassuccessfully aspirated. On the other hand, one of ourpatients (Case 2) had significant calcification and haddeveloped a thick outer lamella when she presentedas early as four months of age. The extent ofcalcification can be determined clinically by palpat-ing for the firmness/hardness of the cephalohema-toma and by CT scan to evaluate the thickness of theouter lamella. Furthermore, the contour of the innerlamella should also be noted on the CT scan. Once theinner lamella is depressed by the cephalohematoma,aspiration alone may not satisfactorily restore skullcontour and a craniectomy and cranioplasty may beneeded even if aspiration was successful in resolvingthe cephalohematoma.

Calcification begins with the formation of a ridgearound the edges of the hematoma and an eggshell-thinlayer under the pericranium. At this stage, thecephalohematoma can be successfully treated byaspiration. Aspiration is performed with a large bore

needle under aseptic conditions and prophylacticantibiotic coverage. The thin shell of calcification canbe gently crushed and this would be incorporated backinto the skull.2 The ridge around the periphery of thehematoma may remain palpable but will resolve withtime. A pressure bandage is applied after aspiration toprevent re-accumulation of the hematoma.

In cases that present late (93Y6 months), thecephalohematoma feels hard and on the CT scan, iscompletely encased by bone. Surgery is the onlyeffective treatment for these calcified cephalo-hematoma.6,7 The indications for surgery for calcifiedcephalohematoma have not been defined.6 In the past,surgery for calcified cephalohematomas has beenactively avoided for fear of complications associatedwith intracranial surgery.2Y5 While Tan3 noted that asthe skull grows, the swelling tend to become lessconspicuous, many patients with this condition whowere treated conservatively had a poor cosmeticoutcome.2 Today, an accepted indication is cosmesis,as this condition can cause significant skull asymmetryand is cosmetically unacceptable. Also, calcifiedcephalohematoma can potentially cause calvarialgrowth disturbances. Martinez-Lage et al21 reporteda case of scaphocephaly secondary to a calcifiedcephalohematoma hindering the growth of the sagittalsuture. While there are currently no reported cases ofcalcified cephalohematoma causing focal neurological

Table 2. Table Summarizing the Causativeand Predisposing Factors, Associations, DifferentialDiagnoses and Complications ofCephalohematomas3,6,8,10,12Y16

Causative/Predisposing Factors for Cephalohematoma

Difficult, prolonged labor

Trauma associated with assisted vaginal delivery, such as forceps- or

vacuum-assisted delivery

Insertion of intra-uterine fetal monitor wire (with a coiled end screwed into

the fetal skull)

High birth weight (4 kg)

Primiparous mother (1st pregnancy)

Bleeding disorders such factor VIII deficiency

Conditions associated with cephalohematoma

Skull fracture

Epidural hematoma

Anemia and jaundice

Differential diagnosis

Caput succedaneum (Subcutaneous hematoma)

Subgaleal hematoma

Encephalocele

Tumors such as dermoid, myofibroma or neuroblastoma

Complications of cephalohematoma

Infection, osteomyelitis and sepsis

Calcification of the cephalohematoma causing skull deformity

Complications of calcified cephalohematoma

Craniosynostosis


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deficits or disturbances in intracranial pressures, thelong-term effects of a calcified mass encroaching intothe cranial vault (in Type 2 calcified cephalohema-toma) on brain development is unknown. Further-more, while our experience with surgical correction ofcalcified cephalohematoma is limited, the safety andefficacy of intracranial surgery for correction of skullasymmetry in other conditions such as craniosynos-tosis in children have been well documented.22Y24 Inour experience, surgery and reconstruction with thetechniques described here consistently yield satisfac-tory results with excellent contour restoration andhave a low morbidity. We therefore recommend

surgical correction for large calcified cephalohema-toma. The optimal timing for surgery howeverremains uncertain. Because of its rarity, the effects ofcalcified cephalohematoma on skull growth and facialsymmetry are difficult to quantitate. Patients can beoperated safely form early infancy onwards. Theyoungest patient we operated on was four month ofage.

When considering surgical correction, the ap-propriate technique depends on the type of calcifiedcephalohematoma as described above.7 In general,Type 1 lesions tend to be smaller calcified lesionswith minimal elevation above the skull.7,11,25 Largercephalohematomas, as those cases reported here,tend to protrude higher above the skull and at thesame time push the pliable inner lamella into thecranial vault and are thus Type 2 lesions. For Type 1calcified cephalohematoma, the pericranium isopened and the outer lamella is separated from theinner lamella either with a drill bit or an osteotome.The organized hematoma within its core is removed.The inner lamella is smoothed with a burr andbleeding is stopped with bone wax. It is notnecessary to enter the cranial cavity.7,11,25 For Type2 calcified cephalohematoma however, a craniect-omy and cranioplasty is necessary to elevate theinner lamella to restore normal skull contour andintracranial volume.7 Two techniques are availableto achieve this and these were described above. Theselection of surgical technique for calvarial recon-struction between the flip-over bull’s-eye techniqueand the cap radial craniectomy technique dependson the preoperative evaluation of CT scans andintraoperative findings. CT scan serves as a usefulguide (Fig 6). The ultimate decision should be madeintraoperatively after confirming the thickness,robustness and contour of the inner and outerlamellas. If the thickness and convexity of theinner lamella is satisfactory, the flip-over bull’s-eyetechnique is an excellent reconstructive option. Thecap radial craniectomy technique can be used withexcellent result in cases that do not fulfill thesecriteria.

The advantages and disadvantages of these twotechniques are as shown in Table 3. The advantagesof the flip-over bull’s-eye technique include itssimplicity and the strength of the reconstruction asthe inner lamella is left intact as a single piece. Also,in properly selected patients, it gives excellentcontour restorations. The cap radial craniectomytechnique, originally described by Kaufman et al6

in 1993, has the main advantage in its versatility. Itcan be used even for severely deformed skull, as longas adequate good quality bone is available. The

Fig 6 Selection of appropriate surgical technique forcalvarium reconstruction for Type 2 calcified cephalohe-matoma based on preoperative CT scan. The ideal skullcontour is marked out in black and an imaginary mirror(white line) drawn at the margins of the calcifiedcephalohematoma. Top: The inner lamella approximatedthe mirrow image of the ideal skull contour and whenflipped over gave excellent contour restoration. Bottom:The inner lamella is irregularly shaped the flip-over bull’s-eye technique would yield a poor result. The cap radialcraniectomy technique would be more appropriate.


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disadvantage is that this is relatively more timeconsuming, requires a lot more contouring andimplants and may be weaker structurally whencompared with the former technique.6,7

An interesting recent innovation for treatment ofcalcifying cephalohematoma with calvarial molding-helmet was reported by Petersen et al.26 The calvaria ina child three to nine months of age is malleable and,therefore, quite easy to shape. The authors presentedtwo cases of partially calcified cephalohematoma(their patients presented at three and four months,respectively) and showed excellent cosmetic result

with the molding-helmet technique. However, whilemolding undoubtedly improve contour, its limitationsshould be recognized. First, as the author stated,molding is only effective partially calcified cephalo-hematoma and probably would yield poor results incompletely calcified cephalohematoma as thosereported in this paper. Second, while molding iseffective in reshaping the skull, this process may pushthe inner lamella of the cephalohematoma further intothe cranial vault, potentially converting a Type 1 into aType 2 lesion. As stated, the effect of this on thedeveloping brain is unknown. Thirdly, after a brief

Fig 7 An algorithm for the manage-ment of cephalohematomas. *The role ofmolding-helmet therapy is yet to bedefined and its routine use is not recom-mended. It can be combined with aspira-tion to reduce recurrence and to achieve abetter shape post-aspiration.


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follow-up (three and five months, respectively),therapy was stopped. The risk of recurrence as thebrain continues to grow, especially in the first twoyears of life, is unknown. Finally, it was unclear whythe authors did not attempt aspiration prior tocommencing molding-helmet therapy, since thesewere minimally or partially calcified cephalohemato-mas.2 Perhaps the combination of aspiration andmolding-helmet would give a better outcome in thissubgroup of patients. Further experience is thereforeneeded define the role of molding therapy in themanagement of calcified cephalohematoma before itsuse can be recommended.

CONCLUSION

Calcification is not an infrequent complication ofcephalohematomas. Awareness and a clear

treatment protocol are important for an optimaloutcome. As noted by Morgan, we should moveaway from the traditional approach of absoluteconservatism to one of active intervention once it isapparent that the cephalohematoma will not sponta-neously resorb and subpericranial osteogenesis isevident.2,3 Early aspiration and pressure dressingsmay prophylactically reduce the incidence of calci-fied cephalohematoma. Surgical options depend onthe type of calcified cephalohematoma and anexcellent outcome can be achieved with appro-priately selected technique.

The authors thank Ms. Ee-Wee Ho for her help with the figures inthis manuscript.

REFERENCES

1. Chorobski J, Davis L. Cyst formations of the skull. SurgGynecol Obstet 1934;58:12

2. Morgan JE. Calcification in cephalhematomata of the newborninfant. Am J Obstet Gynecol 1944;48:702

3. Tan KL. Cephalohematoma. Aust N Z J Obstet Gynaecol1970;10:101

4. Kastendieck H. Zur frage der verknochering von cephalha-matoma. Zentralbl F Gynak 1939;2507:35Y52

5. Ottow Von B. Vollige ossification eines kephalohamatomabeim saugling mit dadurch bedingter bleibender schadelfor-mation. Zentralbl F Gynak 1937;1478:18Y35

6. Kaufman HH, Hochberg J, Anderson RP, et al. Treatment ofcalcified cephalohematoma. Neurosurgery 1993;32:1037Y1039

7. Chung HY, Chung JY, Lee DG, et al. Surgical treatment ofossified cephalohematoma. J Craniofacial Surg 2004;15:774Y779

8. Ingram MD Jr, Hamilton WM. Cephalohematoma in thenewborn. Radiology 1950;55:503

9. Silverman FN, Byrd CR, Fitz CR. The Skull: Traumatic Lesions,9th ed. St. Louis, Mo: Mosby, 1993

10. Hartley JB, Burnett CWF. An enquiry into the causation andcharacteristics of cephalohematomata. Br J radiol 1944;17:33Y41

11. Bruce DA. Cephalohematoma and subgaleal hematoma. In:Wilkins RH, Rengachary SS, eds. Neurosurgery, 2nd edition,vol 2. New York: McGraw-Hill, 2739Y2740

12. Negishi H, Lee Y, Itoh K, et al. Nonsurgical managementof epidural hematoma in neonates. Pediatr Neurol 1989;5: 253Y256

13. Kendall N, Woloshin H. Cephalohematoma associated withfracture of the skull. J Pediatr 1952;41:125Y132

14. Zelson C, Lee SJ, Pearl M. The incidence of skull fracturesunderlying cephalohematomas in new born infants. J Pediatr1974;85:371Y373

15. Listinsky JL, Wood BP, Ekholm SE. Parietal osteomyelitis andepidural abscess: a delayed complication of fetal monitoring.Pediatr Radiol 1986;16:150Y151

16. Overturf GD, Balfour G. Osteomyelitis and sepsis: severecomplications of fetal monitoring. Pediatrics 1975;55:253Y256

17. Huvos AG. Bone Tumors: Diagnosis, Treatment and Progno-sis. Philadelphia, Pa: WB Saunders Company, 1979

18. Mirra JM. Bone Tumors: Clinical, Radiological and Patholog-ical Correlations. Philadelphia, Pa: Lea and Febiger, 1989

19. Thomas JE, Baker HL Jr. Assessment of roentgenographiclucencies of the skull: a systematic approach. Neurology 1975;25:99Y106

20. Firlik KS, Adelson PD. Large chronic cephalohematomawithout calcification. Pediatr Neurosurg 1999;30:39Y42

21. Martinez-Lage JF, Esteban JA, Martinez Perez M, et al.Craniostenosis secondary to calcified subperiosteal hematoma:case report. Neurosurgery 1984;15:703

22. Panchal J, Uttchin V. Management of craniosynostosis. PlastReconstr Surg 2003;111:2032Y2048

23. Fearon JA, Yu J, Bartlett SP, et al. Infections in craniofacialsurgery: a combined report of 567 procedures from twocentres. Plast Reconstr Surg 1997;100:862

24. David DJ, Cooter RD. Craniofacial infection in 10 yearsof transcranial surgery. Plast Reconstr Surg 1987;80:213

25. Fuch HE. Benign tumors of the skull, including fibrousdysplasia. In: Winn HR, ed. Youmans neurological surgery,5th ed, vol 3. Philadelphia: WB Saunders, 3717Y3718

26. Petersen JD, Becker DB, Fundakowski CE, et al. A novelmanagement for calcifying cephalohematoma. Plast ReconstrSurg 2004;113:1404Y1409

Table 3. Advantages and Disadvantages of the CapRadial Craniectomy Technique and the Flip-OverBull’s-eye Technique

Surgical Techniques for

Correction of Type 2

Calcified

Cephalohematoma Advantages Disadvantages

Cap radial craniectomy

technique

Can be used for

severely deformed skull

as long as adequate

good quality bone

is present

Requires a lot more

contouring

Structurally weaker

Flip-over bull’s-eye

technique

Simple

Good contour

restoration in selected

patients

Structurally stronger

Can only be used in

selected cases. Patients

in whom the inner

lamella contour does not

correspond to the

calvarial contour and

patients in whom the

inner lamella is too

thin are not suitable

candidates for

this technique.

Both techniques have a role and complement each other in the surgical

management of calcified cephalohematomas.


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calcified cephalohematoma: classification, indications for...

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