INSIGHTS AND IMAGES www.jpeds.

com • THE JOURNAL OF PEDIATRICS

Vascular Channel Mimicking a Skull Fracture

A
15-month-old boy was referred for magnetic a cause of pediatric pseudofractures or abuse mimics, to our
resonance imaging to evaluate macrocephaly. The knowledge.
magnetic resonance imaging demonstrated a small sub- The American Academy of Pediatrics has published guide-
acute left parietal subdural hematoma (Figure 1, A). The lines for age appropriate evaluation for occult injuries.4 Prompt
medical history was significant for delivery at 32 weeks ges- identification and evaluation of sentinel injuries of abuse is
tation, no prenatal care, prenatal illicit drug exposure, several important due to associated morbidity and mortality.5 Equally
cutaneous hemangiomas below the neck in different phases important is the correct identification of mimics of abuse. These
of evolution, and foster care placement since 1 month of age. complex cases need an interdisciplinary approach to help dif-
Additional medical evaluation included a head computed to- ferentiate fractures from pseudofractures. Thus, vascular vari-
mography with 3-dimensional reconstruction, which identi- ants must be differentiated from skull fractures for accurate
fied only a right frontal bone defect interpreted as a fracture diagnosis and care. ■
(Figure 2; available at www.jpeds.com). Because of the skull
and intracranial findings without a history of trauma, an evalu- Caroline L. S. George, MD
ation for physical abuse was completed. A skeletal survey was Nancy S. Harper, MD
significant for a longitudinal irregularity within the right frontal Department of Pediatrics
bone (Figure 1, B). Re-evaluation of the head computed to-
mography clarified the skull defect as a diploic vein tracking Daniel Guillaume, MD
within the bone causing the calvarial deformity (Video; avail- Department of Neurosurgery
able at: www.jpeds.com).
Skull defects, sometimes described as pseudofractures, include Zuzan Cayci, MD
variation in suture formation1 and neurovascular channels.2 David Nascene, MD
Cranial suture variations have been reported as child abuse Department of Radiology
mimics.3 Enlarged diploic veins and emissary veins (collat- University of Minnesota Masonic Children’s Hospital
eral pathways connecting dural sinuses to the external jugular Minneapolis, Minnesota
circulation) are usually normal variants and can mimic frac-
tures in adults.2 These skull veins have not been identified as References available at www.jpeds.com

Figure 1. A, Axial fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) (subdural hematoma at arrow).
B, Anterior-posterior skull radiograph (vascular channel at arrows, lambdoid suture at arrow heads).

J Pediatr 2017;181:326
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References
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tions: the value of 3D-CT and how to differentiate it from fractures using
3D-CT? Surg Radiol Anat 2010;32:807-16.
2. Koesling S, Kunkel P, Schul T. Vascular anomalies, sutures and small canals
of the temporal bone on axial CT. Eur J Radiol 2005;54:335-43.
Figure 2. A, Head computed tomography (CT) axial bone window. B, Three-dimensional reconstruction demonstrating frontal
bone defect mimicking a fracture (arrows).
INSIGHTS AND IMAGES
3. Tharp AM, Jason DR. Anomalous parietal suture mimicking skull frac-
ture. Am J Forensic Med Pathol 2009;30:49-51.
4. Christian CW. The evaluation of suspected child physical abuse. Pediat-
rics 2015;135:e1337-54.
5. Ravichandiran N, Schuh S, Bejuk M, Al-Harthy N, Shouldice M, Au H,
et al. Delayed identification of pediatric abuse-related fractures. Pediat-
rics 2010;125:60-6.
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