Ten-Year Analysis of Complications Related to Simple Basilar Skull Fractures in Children Presenting to a Trauma Center.

OBJECTIVES: Head trauma is a common presenting complaint among children requiring urgent medical attention, accounting for more than 600,000 emergency department (ED) visits annually, 4% to 30% of which identify skull fractures among the patient's injuries. Previous literature shows that children with basilar skull fractures (BSFs) are usually admitted for observation. We studied whether children with an isolated BSF have complications precluding them from safe discharge home from the ED. METHODS: We performed a retrospective review of ED patients aged 0 to 18 years given a simple BSF diagnosis (defined by nondisplaced fracture, with normal neurologic examination, Glasgow Coma Score of 15, no intracranial hemorrhage, no pneumocephalus) during a 10-year period to identify complications associated with their injury. Complications were defined as death, vascular injury, delayed intracranial hemorrhage, sinus thrombosis, or meningitis. We also considered hospital length of stay (LOS) longer than 24 hours or any return visit within 3 weeks of the original injury. RESULTS: Of the 174 patients included in the analysis, there were no deaths, cases of meningitis, vascular injury, nor delayed bleeding events. Thirty (17.2%) patients required a hospital LOS longer than 24 hours and 9 (5.2%) returned to the hospital within 3 weeks of discharge. Of those with LOS longer than 24 hours, 22 (12.6%) patients needed subspecialty consultation or intravenous fluids, 3 (1.7%) had cerebrospinal fluid leak, and 2 (1.2%) had a concern for facial nerve abnormality. On the return visits, only 1 (0.6%) patient required readmission for intravenous fluids because of nausea and vomiting. CONCLUSIONS: Our findings suggest that patients with uncomplicated BSFs can be safely discharged from the ED if the patient has reliable follow-up, is tolerating oral fluids, has no evidence of cerebrospinal fluid leak, and has been evaluated by appropriate subspecialists before discharge.

Prophylactic Antibiotics in Patients with Traumatic Pneumocephalus or Cerebrospinal Fluid Leak.

INTRODUCTION: Pneumocephalus and cerebrospinal fluid (CSF) leaks are uncommon after trauma, but they expose the sterile CSF to environmental pathogens and create theoretical risk of central nervous system infection (CNSI). Prophylactic antibiotics are commonly given to these patients, but there is a paucity of evidence to guide this practice. We aim to quantify the incidences of these entities and analyze the efficacy of prophylactic antibiotics in preventing CNSIs. METHODS: A retrospective cohort study was conducted using our institutional trauma registry. All patients admitted from January 2014 to July 2020 with traumatic pneumocephalus (TP) or basilar skull fracture with CSF leak (BSF-CSF) were included. ICD-9 and ICD-10 codes were used to identify CNSIs. CNSI rates among defined prophylactic antibiotic regimens, no antibiotics, and other antibiotic regimens were evaluated. ANOVA was used to analyze differences between the groups. RESULTS: 365 patients met inclusion criteria: 360 with TP; 5 with BSF-CSF. 1.1% (4/365) of patients developed CNSI, all with isolated traumatic pneumocephalus. 1.4% of patients (1/72) without antibiotics; 1.2% (3/249) receiving IV antibiotics outside of a defined regimen; and 1.1% (1/88) on a designated prophylactic regimen developed CNSIs. ANOVA indicated the incidence of CNSI was not significantly different among patients who received antibiotics or not, regardless of the regimen (p-value 0.958). CONCLUSION: TP and BSF-CSF are rare diagnoses among trauma patients. The rate of CNSI is marginal and antibiotics do not appear to confer a protective advantage. A larger trial is needed to elucidate the true effect of antibiotics on preventing CNSIs in patients with these uncommon diagnoses.

Cerebrospinal Fluid Leaks After Anterior Skull Base Trauma: A Systematic Review of the Literature.

BACKGROUND: Anterior skull base (ASB) fractures are reported in 4% of head injuries and represent 21% of all skull fractures. Cerebrospinal fluid (CSF) leaks may follow, severely exacerbating outcomes. We systematically reviewed the literature to analyze and compare the roles of endoscopic surgery, open surgery, and combined approaches in the management of CSF leak repair after posttraumatic ASB fractures. METHODS: PubMed, Web of Science, and Scopus databases were searched in accordance with the PRISMA guidelines. Studies reporting clinical data of patients with CSF leaks after ASB fracture were reviewed, focusing on management strategies and posttreatment outcomes. RESULTS: We included 29 articles comprising 888 patients. The average age at diagnosis was 34 years (range, 18-91 years), with a male predominance (54%) and a male/female ratio of 2.9:1 (647:241). Clinical data were available for 888 patients with CSF leaks after ASB fracture, reporting a median follow-up time of 33.5 months (standard deviation, ±29; range, 0.5-330.0 months). Open surgical repair was the most common approach (67.9%), followed by endoscopic surgical repair (32.1%). The endoscopy cohort showed lower rates of complications (0.7% vs. 11.1%) and fistula recurrence (2.8% vs. 5.3%) compared with open surgery. CONCLUSIONS: ASB fractures are frequently treated as late surgery, 24 hours from injury or later, especially for endoscopic surgery. Overall, the endoscopic approach is preferred, mostly because of its safety and effectiveness, offering lower failure rates than does open surgery.

Vestiges of Ossified Spheno-occipital Suture in an Elderly Patient With Down Syndrome and Lateral Skull Base Fracture.

BACKGROUND/AIM: Down syndrome (DS) patients often show characteristic changes in the skull, e.g. short cranial base. The synchondroses of the skull base have a significant influence on the shape of the skull. The sphenooccipital synchondrosis (SOS) is the last of the basal synchondroses to ossify. This report is about residual ossification of SOS in an elderly patient with DS. CASE REPORT: The 65-year-old DS patient was polytraumatized by a fall. In the course of treatment, a purulent otitis externa on the right side was diagnosed, which had developed as a result of the fracture of the fossa glenoidalis. Computed tomograms of the skull base showed the fracture of the mandibular condyle, glenoid fossa and vestiges of SOS. CONCLUSION: The coincidental finding of vestiges of SOS in an elderly patient with DS raises the question of whether cross-sectional skull base images can show differences in the ossification of SOS between DS patients and a normal population.

Acute hydrocephalus secondary to traumatic perimesencephalic pneumocephalus: A case report.

INTRODUCTION: Acute hydrocephalus is a common complication of spontaneous or traumatic intracranial bleeding with extensive subarachnoid hemorrhage (SAH) or ventricular extension. However, it has never been reported to be secondary to pneumocephalus. PATIENT CONCERNS: A 32-year-old man was admitted following a motorcycle accident. Head computed tomography (CT) performed right after the accident revealed a skull base fracture and mild perimesencephalic SAH. Three days later, repeated CT revealed delayed perimesencephalic pneumocephalus and an evident enlargement of the ventricular system. DIAGNOSIS: The patient was diagnosed with acute obstructive hydrocephalus, which was secondary to pneumocephalus and traumatic SAH. INTERVENTIONS: The patient was treated with temporary external ventricular drainage (EVD). OUTCOMES: The patient experienced an unremarkable recovery process. At follow-up 3 months later, he showed no recurrence of the hydrocephalus and the score of Glasgow Outcome Scale was 5. CONCLUSION: Transient mechanical obstruction of CSF circulation and disturbance of CSF physiology might conjointly lead to the acute obstructive hydrocephalus.

Isolated Increased Intracranial Pressure and Unilateral Papilledema in an Infant With Traumatic Brain Injury and Nondepressed Basilar Skull Fracture.

Traumatic brain injury is one of the most common pediatric injuries; totaling more than 500,000 emergency department visits per year. When the injury involves a skull fracture, sinus venous thrombosis and the risk of resultant increased intracranial pressure (ICP) are a concern. We describe a previously healthy 11-month-old female infant with nondepressed skull fracture who developed increased ICP in the absence of intracranial changes on imaging. Funduscopic examination revealed unilateral papilledema, and opening pressure on lumbar puncture was elevated at 35 cm of H2O. Computed tomography scan demonstrated a nondepressed occipital bone fracture. However, further imaging, including magnetic resonance imaging with angiogram/venogram, did not reveal any intracranial abnormalities. In particular, there was no evidence of sinus venous thrombosis. Given her presentation and signs of increased ICP, she was started on acetazolamide and improved dramatically. A thorough literature search was completed but yielded no information on infants with increased ICP after nondepressed skull fracture in the absence of radiographic findings to suggest a cause for the increase in pressure. Trauma alone can lead to increased ICP secondary to several processes, although this is expected in moderate to severe head trauma. Our case demonstrates that increased ICP can be present in infants with mild traumatic brain injury in the absence of intracranial pathology. This should be considered in patients who present with persistent vomiting that is refractory to antiemetics.

Entrapment of the basilar artery within a clivus fracture: Case report and literature review.

A review of the literature revealed that basilar artery (BA) entrapment is a very rare (17 cases published) and severe pathological condition, which often leads to death. We report the case of a 72-year-old man who presented with a longitudinal clivus fracture associated with a basilar artery entrapment. This entrapment was responsible for a basilar artery dissection, which led to an ischemic stroke in the pons. The patient was managed with medical treatment, mainly to avoid a progression towards an ischemic stroke. It consisted of heparin therapy followed by antiplatelet therapy, which finally resulted in a successful outcome. In BA entrapment most of the patients who had a favorable outcome received antithrombotic therapy. This suggests that antithrombotic therapy might be useful in the first line treatment of post-traumatic BA entrapment.

Misplaced incus: an unusual complication of a temporal bone fracture.

A 24-year-old man sustained significant injuries as a result of a motor bicycle accident. CT scans demonstrated multiple intracranial injuries including bilateral temporal bone fractures. On emergence from sedation, the patient reported right-sided hearing loss which was attributed to ossicular chain disruption after the incus was found to be in the external auditory canal. Unexpectedly, the initial conductive hearing loss resolved with conservative management and an ossicular chain reconstruction was not required. This is an unusual case of impressive long-term good hearing outcomes following complete dislocation of the incus and extrusion from the middle ear.

Neuromuscular electrical stimulation on hearing loss caused by skull base fracture: A protocol for systematic review of randomized controlled trial.

BACKGROUND: This systematic review aims to investigate the effectiveness and safety of neuromuscular electrical stimulation (NMES) on hearing loss (HL) caused by skull base fracture (SBF). METHODS: We will retrieve the following electronic databases of Cochrane Library, PUBMED, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, and Chinese Biomedical Literature Database from the inception to January 1, 2019 for relevant RCTs of NMES for HL caused by SBF. Two experienced authors will independently perform the study selection, data extraction, and methodology quality assessment. A 3rd author will solve any disagreements between 2 authors through discussion. RESULTS: This study will provide a high-quality synthesis of latest evidence of NMES for HL caused by SBF from comprehensive assessments, including hearing loss evaluation, hearing threshold, quality of life, and any relevant adverse events. CONCLUSION: The expected results of this systematic review will provide the up-to-date evidence to assess the effectiveness and safety of NEMS for patients with HL caused by SBF. ETHICS AND DISSEMINATION: The results of this study will be disseminated through publication in a peer-reviewed journal or will be presented at an associated conference meeting. This study will not use individual patient data, thus, the ethical approval is not needed. PROSPERO REGISTRATION NUMBER: PROSPERO CRD42019120195.

Clinical Significance of Long-Term Follow-Up of Children with Posttraumatic Skull Base Fracture.

OBJECTIVE: To assess the incidence of cerebrospinal fluid (CSF) leak and meningitis, and the need for prophylactic antibiotics, antipneumococcal vaccination, and surgical interventions, in children with a skull base fracture. METHODS: We reviewed the records of children with a skull base fracture who were admitted to our tertiary care center between 2009 and 2014. RESULTS: A total of 196 children (153 males), age 1 month to 18 years (mean age, 6 ± 4 years), were hospitalized with skull base fracture. Causes of injury were falls (n = 143), motor vehicle accidents (n = 34), and other (n = 19). Fracture locations were the middle skull base in 112 patients, frontal base in 62, and occipital base in 13. Fifty-four children (28%) had a CSF leak. In 34 of these children (63%), spontaneous resolution occurred within 3 days. Three children underwent surgery on admission owing to a CSF leak from an open wound, 3 underwent CSF diversion by spinal drainage, and 4 (2%) required surgery to repair a dural tear after failure of continuous spinal drainage and acetazolamide treatment. Twenty-eight children (14%) received prophylactic antibiotic therapy, usually due to other injuries, and 11 received pneumococcal vaccination. Two children developed meningitis, and 3 children died. Long-term follow up in 124 children revealed 12 children with delayed hearing loss and 3 with delayed facial paralysis. CONCLUSIONS: This is the largest pediatric series of skull base fractures reporting rates of morbidity and long-term outcomes published to date. The rate of meningitis following skull base fracture in children is low, supporting a policy of not administering prophylactic antibiotics or pneumococcal vaccine. Long-term follow up is important to identify delayed complications.

Traumatic basilar artery entrapment with patency of pontine perforators and absence of significant brainstem infarction: report of an unusual case.

We report a rare case of entrapment of the basilar artery into the sphenoid bone caused by a longitudinal fracture of the clivus. Using high resolution three-dimensional flat panel angiography, we show preservation of the basilar artery perforators in spite of severe stenosis of the entrapped segment of the basilar artery. There were no obvious signs and symptoms of posterior fossa stroke clinically or radiographically as far as could be assessed under given clinical circumstances.

[Oculorrhea after facial fracture and anterior skull base fracture]. / Okulorré efter ansiktsfraktur och främre skallbasfraktur - Första svenska beskrivningen av läckage av cerebrospinalvätska kranioorbitalt.

Leakage of cerebrospinal fluid (CSF) from a cranio-orbital fistula, i.e. oculorrhea, is rare after skull trauma with fewer than 30 patients reported in Western literature. Here, we for the first time report a Swedish patient. A 75-year-old male sustained a mid-facial injury due to a bicycle accident. The CT-scan showed, among other things, a fracture in the orbital roof, involving lamina cribrosa and lamina papyracea. The patient had epiphora and laboratory analysis showed CSF leakage. This diagnosis should be kept in mind when excessive tearing appears in mid-facial trauma and treatment should be considered, otherwise serious complications may occur.

Traumatic intracranial internal carotid artery pseudoaneurysm presenting as epistaxis treated by endovascular coiling.

Traumatic intracranial pseudoaneurysm is a rare complication of blunt trauma. It is even more rare when it presents as epistaxis. Massive epistaxis of a ruptured intracranial internal carotid artery pseudoaneurysm is a major cause of mortality, which requires emergency intervention. We report a case of traumatic intracranial internal carotid artery pseudoaneurysm secondary to skull base fracture, which presented with delayed onset of epistaxis. This was successfully treated by primary endovascular coil embolization. We discuss endovascular treatment options and review the literature.

Basilar skull fractures: the petrous bone.

Basilar skullfractures: the petrous bone. OBJECTIVES: to provide suggestions for the management of three of the most dangerous or important lesions (internal carotid artery lesions, cerebrospinal fluid leaks and facial nerve paralysis) associated with the petrous part of basilar skull fractures, thereby trying to assess categories of evidence and determine strengths of recommendation. METHODOLOGY: A PubMed-based literature review was carried out, as well as a consultation of online sources as encountered in the literature review. Also, a non-systematic search of chapters of well-known books dealing with the subject of temporal bone traumata was conducted. RESULTS: Specific levels of evidence and/or strength of recommendation can be retrieved from the literature, but only with respect to the prophylactic use of antibiotics, the prescription of antithrombotic medications and the indications for angiography. CONCLUSION: The ample amount of available literature allows for sound management decisions, with reference made to algorithms when available in the literature. Nevertheless, for most of the management/search questions, categories of evidence and strength of recommendation are low or lacking.

Frontobasal Fractures.

Frontobasal fractures occur in up to 24% of head injuries and often require a multidisciplinary approach. Besides the common bone fractures, the complex anatomy can cause damage to the sense of vision and smell. Further possibly lethal complications such as cerebrospinal fluid leak followed by meningitis or internal carotid bleeding can follow. Diagnostic and treatment options are reviewed with a focus on the endoscopic endonasal approach.

Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures.

BACKGROUND: Basilar skull fractures predispose patients to meningitis because of the possible direct contact of bacteria in the paranasal sinuses, nasopharynx or middle ear with the central nervous system (CNS). Cerebrospinal fluid (CSF) leakage has been associated with a greater risk of contracting meningitis. Antibiotics are often given prophylactically, although their role in preventing bacterial meningitis has not been established. OBJECTIVES: To evaluate the effectiveness of prophylactic antibiotics for preventing meningitis in patients with basilar skull fractures. SEARCH METHODS: We searched CENTRAL (2014, Issue 5), MEDLINE (1966 to June week 1, 2014), EMBASE (1974 to June 2014) and LILACS (1982 to June 2014). We also performed an electronic search of meeting proceedings from the American Association of Neurological Surgeons (1997 to September 2005) and handsearched the abstracts of meeting proceedings of the European Association of Neurosurgical Societies (1995, 1999 and 2003). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing any antibiotic versus placebo or no intervention. We also identified non-RCTs to perform a separate meta-analysis in order to compare results. DATA COLLECTION AND ANALYSIS: Three review authors independently screened and selected trials, assessed risk of bias and extracted data. We sought clarification with trial authors when needed. We pooled risk ratios (RRs) for dichotomous data with their 95% confidence intervals (CIs) using a random-effects model. We assessed the overall quality of evidence using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. MAIN RESULTS: In this update we did not identify any new trials for inclusion. We included five RCTs with 208 participants in the review and meta-analysis. We also identified 17 non-RCTs comparing different types of antibiotic prophylaxis with placebo or no intervention in patients with basilar skull fractures. Most trials presented insufficient methodological detail. All studies included meningitis in their primary outcome. When we evaluated the five included RCTs, there were no significant differences between antibiotic prophylaxis groups and control groups in terms of reduction of the frequency of meningitis, all-cause mortality, meningitis-related mortality and need for surgical correction in patients with CSF leakage. There were no reported adverse effects of antibiotic administration, although one of the five RCTs reported an induced change in the posterior nasopharyngeal flora towards potentially more pathogenic organisms resistant to the antibiotic regimen used in prophylaxis. We performed a subgroup analysis to evaluate the primary outcome in patients with and without CSF leakage. We also completed a meta-analysis of all the identified controlled non-RCTs (enrolling a total of 2168 patients), which produced results consistent with the randomised data from the included studies.Using the GRADE approach, we assessed the quality of trials as moderate. AUTHORS' CONCLUSIONS: Currently available evidence from RCTs does not support prophylactic antibiotic use in patients with basilar skull fractures, whether there is evidence of CSF leakage or not. Until more research is available, the effectiveness of antibiotics in patients with basilar skull fractures cannot be determined because studies published to date are flawed by biases. Large, appropriately designed RCTs are needed.

Traumatic ossicular disruption with isolated fracture of the stapes suprastructure: comparison with incudostapedial joint dislocation.

CONCLUSION: More severe high frequency hearing loss, especially at 8 kHz, occurs with fracture of the stapes suprastructure (SSF) compared with isolated incudostapedial joint dislocation (ISD). Successful hearing gain can be achieved in the speech range with appropriate ossicular reconstruction. OBJECTIVES: Traumatic SSF is a rare consequence of head trauma. This study aimed to demonstrate the characteristic features of SSF compared with traumatic ISD. METHODS: Eighteen patients who suffered from conductive hearing loss after head trauma and were operated from 2000 to 2012 were enrolled. Eight and 10 patients were confirmed to have a traumatic SSF (SSF group) and ISD (ISD group), respectively. The etiology of ossicular disruption, preoperative CT scan of the temporal bone, and intraoperative findings were retrospectively reviewed. Pre- and postoperative hearing was analyzed by both pure tone averages and thresholds at each frequency (0.5-8 kHz). RESULTS: The most common etiologies in the SSF group were fall (n = 3) and direct ear trauma (n = 3), and for those in the ISD group, the most common etiology was traffic accident (n = 6). CT scan showed no evidence of fracture in the SSF group, whereas findings of ossicular dislocation were found in 70% of patients in the ISD group. Hearing outcomes according to the frequencies demonstrated that pre- and postoperative hearing loss at 8 kHz was more severe in the SSF group than in the ISD group. In a comparison of hearing outcomes at each frequency, the postoperative hearing threshold at 8 kHz was higher than for other frequencies. Postoperatively, 63% of the SSF group and 70% of the ISD group obtained an air-bone gap of within 15 dB.

Defining pediatric orbital roof fractures: patterns, sequelae, and indications for operation.

BACKGROUND: There are few published data addressing pediatric orbital roof fractures, particularly regarding long-term outcomes and indications for operative intervention. To provide evidence-based guidelines for the management of these injuries, the authors examined a large cohort of patients with this injury pattern. METHODS: Institutional review board approval was obtained to review pediatric patients presenting to Johns Hopkins Hospital from 1991 to 2011. All patients with a diagnosis indicating orbital or skull base fractures were reviewed to determine orbital roof involvement. Patients with roof fractures were assessed for demographics, management, and outcomes. RESULTS: A total of 1484 pediatric patients carried the diagnoses of orbital fracture or anterior skull base fracture. After review, 159 patients (11 percent) were found to have true orbital roof fractures, with 36 percent being comminuted. One hundred five patients returned after discharge (average follow-up, 19 months). One patient developed vertical dystopia 10 months after being lost to follow-up with a large, comminuted fracture. Ten patients underwent surgery to repair the orbital roof. Inferior displacement correlated with need for surgical repair (p < 0.001). CONCLUSIONS: In the largest study to date analyzing pediatric orbital roof fractures, the authors found that most can be managed conservatively with good long-term outcomes. Vertical dystopia occurred in less than 1 percent of patients and was associated with large, comminuted fractures. Inferiorly displaced and fractures with a surface area over 2 cm represent higher risk fractures that should be followed closely for possible intervention based on the development of sequelae such as vertical dystopia or encephalocele. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.