Epidemiology of Anterior and Lateral Basilar Skull Fractures With CSF Leak: A National Trauma Data Bank Analysis.

OBJECTIVE: Cerebrospinal fluid (CSF) leaks are a complication from dural violations that can occur in the setting of skull base fractures. No prior study provides a nationwide epidemiological analysis of traumatic CSF leaks. The objective of this report is to characterize patient demographics, injury-related variables, and operative management. METHODS: The national trauma data bank was queried for both anterior and lateral skull base fracture cases between 2008 and 2016. Clinical data were extracted. RESULTS: A total of 242 skull base fractures with CSF leak were identified. Most patients were male (84.3%), and the median patient age was 39.7±17.6 years old. Glasgow Coma Scale was 14.0 [interquartile range (IQR): 6.5-10.6] for lateral fractures, 13.0 (IQR: 3.0-10.0) for anterior fractures, and severe range for combined fractures at 7.0 (IQR: 5.0-9.0) (analysis of variance, P =0.122). Common mechanisms of injury were motor vehicle accidents (107, 44.2%), followed by falls and firearms (65, 26.9% and 20, 8.3%, respectively). The median length of stay was 2 weeks, with a median of 14 days (IQR: 10-25) for the anterior fractures and 10 days (IQR 5-19) among the lateral fractures ( P =0.592). Patients were most commonly discharged home in both the anterior (43.8%) and lateral (49.2%) groups. CONCLUSIONS: The prototypical patient tends to be a young adult male presenting with moderate-to-severe range neurological dysfunction after a vehicular accident. The overall prognosis of skull base fractures with CSF leak remains encouraging, with nearly half of these patients being discharged home within 2 weeks.

[Basilar skull fractures]. / Schädelbasisfrakturen.

CLINICAL ISSUE: Basilar skull fractures are fractures of the lower part of the skull. They make up about 20% of all skull fractures and are mainly caused by high-velocity blunt trauma and falls from high heights. Depending on their precise location, they can be divided into frontobasal, laterobasal and frontolateral fractures. Possible clinical signs are the presence of cerebrospinal fluid rhinorrhea or otorrhea, periorbital ecchymosis (raccoon eyes), retroauricular ecchymosis (battle sign) and cranial nerve injuries. Furthermore, fractures of the petrous bone can lead to a conductive hearing loss, sensorineural hearing loss as well as dizziness and nausea due to a failure of the labyrinth. PRACTICAL RECOMMENDATIONS: If there are any clinical signs of a basilar skull fracture, neurological deficits or limited consciousness (GCS < 15), a CT should be performed to rule out a basilar skull fracture and accompanying pathologies. In addition, if vascular injury is suspected, a CT angiography should be performed. Treatment is usually interdisciplinary and depends mainly on the accompanying injuries and possible complications. A purely conservative approach with close controls (with imaging) is often sufficient. The surgical approach is primarily used to treat possible complications, for example intracerebral bleeding.

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.

Risk Factors in Pediatric Blunt Cervical Vascular Injury and Significance of Seatbelt Sign.

INTRODUCTION: Computed tomography angiography (CTA) is used to screen patients for cerebrovascular injury after blunt trauma, but risk factors are not clearly defined in children. This modality has inherent radiation exposure. We set out to better delineate the risk factors associated with blunt cervical vascular injury (BCVI) in children with attention to the predictive value of seatbelt sign of the neck. METHODS: We collected demographic, clinical and radiographic data from the electronic medical record and a trauma registry for patients less than age 18 years who underwent CTA of the neck in their evaluation at a Level I trauma center from November 2002 to December 2014 (12 years). The primary outcome was BCVI. RESULTS: We identified 11,446 pediatric blunt trauma patients of whom 375 (2.7%) underwent CTA imaging. Fifty-three patients (0.4%) were diagnosed with cerebrovascular injuries. The average age of patients was 12.6 years and included 66% males. Nearly half of the population was white (52%). Of those patients who received CTA, 53 (14%) were diagnosed with arterial injury of various grades (I-V). We created models to evaluate factors independently associated with BCVI. The independent predictors associated with BCVI were Injury Severity Score >/= 16 (odds ratio [OR] [2.35]; 95% confidence interval [CI] [1.11-4.99%]), infarct on head imaging (OR [3.85]; 95% CI [1.49-9.93%]), hanging mechanism (OR [8.71]; 95% CI [1.52-49.89%]), cervical spine fracture (OR [3.84]; 95% CI [1.94-7.61%]) and basilar skull fracture (OR [2.21]; 95% CI [1.13-4.36%]). The same independent predictors remained associated with BCVI when excluding hanging mechanism from the multivariate regression analysis. Seatbelt sign of the neck was not associated with BCVI (p=0.68). CONCLUSION: We have found independent predictors of BCVI in pediatric patients. These may help in identifying children that may benefit from screening with CTA of the neck.

Clinical Signs of Basilar Skull Fracture and Their Predictive Value in Diagnosis of This Injury.

Although clinical signs for the diagnosis of basilar skull fracture (BSF) are ambiguous, they are widely used to make decisions on initial interventions involving trauma patients. We aimed to assess the performance of early and late (within 48 hr posttrauma) signs for BSF diagnosis and to verify the correlation between the presence of these signs and head injury severity. We conducted a prospectively designed follow-up study at a referral hospital for trauma care in Sao Paulo, Brazil, and performed structured observations for 48 hr post-blunt head injury in patients aged 12 years or older. The following signs of BSF were considered: raccoon eyes, Battle's sign, otorrhea, and rhinorrhea. Among the 136 enrolled patients (85.3% male; mean age 40 ± 21.4 years), 28 patients (20.6%) had BSF. The clinical signs for the early or late detection of BSF had low accuracy (55.9% vs. 43.4%), specificity (52.8% vs. 30.5%), and positive predictive value (25.7% vs. 27.1%). However, the presence of these signs was correlated to head injury severity, indicated by the Glasgow Coma Scale (p = .041) and Maximum Abbreviated Injury Scale-Head region (p = .002). In view of the low accuracy of these signs, resulting low clinical value of their presence, and their high sensitivity in the late stage, the study results contraindicate the value of BSF signs for making decisions about using the nasal route for the introduction of catheters and tubes in initial trauma care.

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.

Basilar Artery Herniation into the Sphenoid Sinus Secondary to Traumatic Skull Base Fractures: Case Report and Review of the Literature.

BACKGROUND: Traumatic clival fractures occur with less than 0.6% frequency and can be associated with significant neurovascular injuries. The most serious of these injuries is to the basilar artery in which the artery is dissected or is fully occluded, resulting in infarction of the brainstem and cerebellum. Among early reports of these injuries, postmortem autopsy showed entrapment, or incarceration, of the basilar artery at the clival fracture site. A literature search revealed 11 cases of entrapment of the basilar artery within a clival fracture. CASE DESCRIPTION: This report describes a 59-year-old man after a motor vehicle crash with computed tomography showing a basilar artery herniation through a sphenoid sinus fracture. The patient subsequently developed brainstem and cerebellar infarcts. CONCLUSIONS: Basilar artery incarceration and herniation through the sphenoid sinus is rare. Such an injury portends a poor prognosis. We discuss the relevant clinical imaging and review the literature.

Clinical Presentations and Outcomes of Children With Basilar Skull Fractures After Blunt Head Trauma.

STUDY OBJECTIVE: We describe presentations and outcomes of children with basilar skull fractures in the emergency department (ED) after blunt head trauma. METHODS: This was a secondary analysis of an observational cohort of children with blunt head trauma. Basilar skull fracture was defined as physical examination signs of basilar skull fracture without basilar skull fracture on computed tomography (CT), or basilar skull fracture on CT regardless of physical examination signs of basilar skull fracture. Other definitions included isolated basilar skull fracture (physical examination signs of basilar skull fracture or basilar skull fracture on CT with no other intracranial injuries on CT) and acute adverse outcomes (death, neurosurgery, intubation for >24 hours, and hospitalization for ≥2 nights with intracranial injury on CT). RESULTS: Of 42,958 patients, 558 (1.3%) had physical examination signs of basilar skull fracture, basilar skull fractures on CT, or both. Of the 525 (94.1%) CT-imaged patients, 162 (30.9%) had basilar skull fracture on CT alone, and 104 (19.8%) had both physical examination signs of basilar skull fracture and basilar skull fracture on CT; 269 patients (51.2%) had intracranial injuries other than basilar skull fracture on CT. Of the 363 (91.7%) CT-imaged patients with physical examination signs of basilar skull fracture, 104 (28.7%) had basilar skull fracture on CT. Of 266 patients with basilar skull fracture on CT, 104 (39.1%) also had physical examination signs of basilar skull fracture. Of the 256 CT-imaged patients who had isolated basilar skull fracture, none had acute adverse outcomes (0%; 95% confidence interval 0% to 1.4%), including none (0%; 95% confidence interval 0% to 6.1%) of 59 with isolated basilar skull fractures on CT. CONCLUSION: Approximately 1% of children with blunt head trauma have physical examination signs of basilar skull fracture or basilar skull fracture on CT. The latter increases the risk of acute adverse outcomes more than physical examination signs of basilar skull fracture. A CT scan is needed to adequately stratify the risk of acute adverse outcomes for these children. Children with isolated basilar skull fractures are at low risk for acute adverse outcomes and, if neurologically normal after CT and observation, are candidates for ED discharge.

[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.

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.

Imaging of temporal bone trauma.

Temporal bone trauma is commonly seen in patients with craniofacial injury and can be detected using multidetector computed tomography. A thorough understanding of the different types of temporal bone fracture patterns is needed to accurately describe the trajectory of injury as well as anticipated complications. Fractures should be described based on direction, segment of temporal bone involved, as well as involvement of the otic capsule. More importantly, the radiologist plays an integral role in identifying complications of temporal bone injury, which often have significant clinical implications.

Skull base fractures and their complications.

Basilar skull fractures are a relatively frequent occurrence in significant head trauma, and their detection is important, as even linear nondisplaced fractures can be associated with critical complications. The management of skull base fractures depends on the location and extent of these associated complications. This article reviews skull base anatomy; morphology of the common fracture patterns within the anterior, central, and posterior skull base; associated complications; imaging findings; and possible pitfalls in imaging of skull base trauma.

Late complication of the frontobasal trauma.

The injuries of the frontobasal region are always a great challenge to a surgeon, especially the management of bone defects of the frontal region. The authors present a patient with late, 33-year postaccident complication, which had been surgically treated, and whose frontal bone defect had been reconstructed with methyl methacrylate. Clinical examination and computed tomography confirmed signs of previous operation and presence of an infection and alloplastic material. Specific for this case was challenge to manage chronic infection and reestablish integrity of the skull in the frontal region. Out of a variety of autogenous or alloplastic materials, and considering the extent of bone defect and previous episodes of treatment aimed at aesthetic and functional results with good prognosis, we opted for reconstruction of the frontal region defect with combined titanium mesh impregnated with the hydroxyapatite cement.