Decreased Incidence of CSF Leaks after Skull Base Fractures in the 21st Century: An Institutional Report

Abstract

Objectives Cerebrospinal fluid (CSF) leaks are a possible complication in patients with skull base fractures (SBFs). The widely cited incidence of CSF leaks is 10 to 30% in SBF patients; however, this estimate is based only on a few outdated studies. A recent report found CSF leaks in <2% SBF patients, suggesting the incidence may be lower now. To investigate this, we report here our institutional series.

Design This study is a retrospective chart review.

Setting The study was conducted at two major academic medical centers (2000–2018).

Participants Adult patients with SBF were included in this study.

Main Outcome Measures Variables included age, gender, CSF leak within 90 days, management regimen, meningitis within 90 days, and 1-year mortality.

Results Among 4,944 patients with SBF, 199 (4%) developed a CSF leak. SBF incidence was positively correlated with year of clinical presentation (r-squared 0.78, p < 0.001). Among CSF leaks, 42% were conservatively managed, 52% were treated with lumbar drain, and 7% required surgical repair. Meningitis developed in 28% CSF leak patients. The 1-year mortality for all SBF patients was 11%, for patients with CSF leaks was 12%, and for patients with meningitis was 16%.

Conclusion In the largest institutional review of SBF patients in the 21st century, we found CSF leak incidence to be 4%. This is lower than the widely cited range of 10 to 30%. Nevertheless, morbidity and mortality associated with this complication remains clinically significant, and SBF patients should continue to be monitored for CSF leaks. We provide here our institutional treatment algorithm for these patients that may help to inform the treatment strategy at other institutions.

Keywords

CSF leak - cerebrospinal fluid otorrhea - cerebrospinal fluid rhinorrhea - skull base fracture - basilar skull fracture

• References

• 1 Taylor CA, Bell JM, Breiding MJ, Xu L. Traumatic Brain Injury-Related Emergency Department Visits, Hospitalizations, and Deaths – United States, 2007 and 2013. MMWR Surveill Summ 2017; 66 (09) 1-16
• 2 Mandrioli S, Tieghi R, Galiè M, Denes SA, Pagliaro F, Clauser L. Anterior skull base fractures: guidelines for treatment. J Craniofac Surg 2008; 19 (03) 713-717
• 3 Phang SY, Whitehouse K, Lee L, Khalil H, McArdle P, Whitfield PC. Management of CSF leak in base of skull fractures in adults. Br J Neurosurg 2016; 30 (06) 596-604
• 4 Lin DT, Lin AC. Surgical treatment of traumatic injuries of the cranial base. Otolaryngol Clin North Am 2013; 46 (05) 749-757
• 5 Baugnon KL, Hudgins PA. Skull base fractures and their complications. Neuroimaging Clin N Am 2014; 24 (03) 439-465 , vii–viii
• 6 Abuabara A. Cerebrospinal fluid rhinorrhoea: diagnosis and management. Med Oral Patol Oral Cir Bucal 2007; 12 (05) E397-E400
• 7 Oh JW, Kim SH, Whang K. Traumatic cerebrospinal fluid leak: diagnosis and management. Korean J Neurotrauma 2017; 13 (02) 63-67
• 8 Archer JB, Sun H, Bonney PA. et al. Extensive traumatic anterior skull base fractures with cerebrospinal fluid leak: classification and repair techniques using combined vascularized tissue flaps. J Neurosurg 2016; 124 (03) 647-656
• 9 Aarabi B, Leibrock LG. Neurosurgical approaches to cerebrospinal fluid rhinorrhea. Ear Nose Throat J 1992; 71 (07) 300-305
• 10 Ratilal BO, Costa J, Pappamikail L, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev 2015; CD004884 (04) CD004884
• 11 Abrishamkar S, Khalighinejad N, Moein P. Analysing the effect of early acetazolamide administration on patients with a high risk of permanent cerebrospinal fluid leakage. Acta Med Iran 2013; 51 (07) 467-471
• 12 Friedman JA, Ebersold MJ, Quast LM. Persistent posttraumatic cerebrospinal fluid leakage. Neurosurg Focus 2000; 9 (01) e1
• 13 Brawley BW, Kelly WA. Treatment of basal skull fractures with and without cerebrospinal fluid fistulae. J Neurosurg 1967; 26 (01) 57-61
• 14 Kral T, Zentner J, Vieweg U, Solymosi L, Schramm J. Diagnosis and treatment of frontobasal skull fractures. Neurosurg Rev 1997; 20 (01) 19-23
• 15 Brodie HA, Thompson TC. Management of complications from 820 temporal bone fractures. Am J Otol 1997; 18 (02) 188-197
• 16 Choi D, Spann R. Traumatic cerebrospinal fluid leakage: risk factors and the use of prophylactic antibiotics. Br J Neurosurg 1996; 10 (06) 571-575
• 17 Dagi TF, Meyer FB, Poletti CA. The incidence and prevention of meningitis after basilar skull fracture. Am J Emerg Med 1983; 1 (03) 295-298
• 18 Chan DTM, Poon WS, Ip CP, Chiu PW, goh KY. How useful is glucose detection in diagnosing cerebrospinal fluid leak? The rational use of CT and Beta-2 transferrin assay in detection of cerebrospinal fluid fistula. Asian J Surg 2004; 27 (01) 39-42
• 19 McCutcheon BA, Orosco RK, Chang DC. et al. Outcomes of isolated basilar skull fracture: readmission, meningitis, and cerebrospinal fluid leak. Otolaryngol Head Neck Surg 2013; 149 (06) 931-939
• 20 Sherif C, Di Ieva A, Gibson D. et al. A management algorithm for cerebrospinal fluid leak associated with anterior skull base fractures: detailed clinical and radiological follow-up. Neurosurg Rev 2012; 35 (02) 227-237 , discussion 237–238
• 21 Scholsem M, Scholtes F, Collignon F. et al. Surgical management of anterior cranial base fractures with cerebrospinal fluid fistulae: a single-institution experience. Neurosurgery 2008; 62 (02) 463-469 , discussion 469–471
• 22 Le C, Strong EB, Luu Q. Management of anterior skull base cerebrospinal fluid leaks. J Neurol Surg B Skull Base 2016; 77 (05) 404-411
• 23 Thapa AJ, Lei BX, Zheng MG, Li ZJ, Liu ZH, Deng YF. The surgical treatment of posttraumatic skull base defects with cerebrospinal fluid leak. J Neurol Surg B Skull Base 2018; 79 (02) 205-216