Fractures of the Anterior Skull Base Associated with CSF Leak

Abstract

Background: Fractures of the anterior skull base with or without cerebrospinal fluid (CSF) leak still remain a therapeutic challenge and are topic of controversial discussions. Clear strategic and therapeutic concepts are still lacking. Clinical Findings: A simple, but effective classification system has been created similar to the Glasgow Coma Scale to provide a useful patient selection. Diagnostics: Besides a neurological examination some clinical adjunctive possibilities are recommended, such as, for example, the Valsalva manoeuvre, use of a glucose test strip, or the presence of a double ring sign; also a beta-2-transferrin test and intrathecal fluorescent application are possibly useful. Initial CT scans and non-contrast high-resolution CT with 1 mm slices are standard examinations. MRI scans are recommended for delayed brain abscess or meningitis. Surgical Strategies: Patients with acute surgical indications require immediate operation. Patients without acute indications should be operated within 14 days after clinical stabilization. Patients with persistent CSF leak or a chronic brain abscess/meningitis should be operated after special diagnosis and observation. No operation is indicated for patients without clinical rhinorrhoea and just tiny air bubbles in the CT scan or a CSF leak for less than 5 days. All patients need antibiotic protection for about 5 to 10 days. The additional use of lumbar drainage is highly recommended. Surgical Technique: A pediculated galea/periosteal flap for reconstruction, an uni- or sometimes bifrontal craniotomy and, above all, intradural microsurgical techniques are fundamental for a successful surgical outcome. Conclusions: Only a close interdisciplinary cooperation between diagnostics, surgery, ICU and rehabilitation provide favourable clinical results.

Key words

Anterior skull base fracture - CSF leak - traumatic brain injury

References

• 1 Beckhardt R N, Setzen M, Carras R. Primary spontaneous cerebrospinal fluid rhinorrhoea.  Otolaryngol Head Neck Surg. 1991;  104 425-432
• 2 Bell R B, Dierks E, Homer L, Potter B. Management of cerebrospinal fluid leak associated with craniomaxillofacial trauma.  J Oral Maxillofac Surg. 2004;  62 676-684
• 3 Caldicott D, Pearce A, Price R, Croser D, Brophy B. Not just another “head lac” … low velocity, penetrating intracranial injuries: a case report and review of the literature. Injury.  Int J Care Injured. 2004;  35 1044-1054
• 4 Connor S EJ, Flis C. The contribution of high-resolution multiplanar reformats of the skull base to the detection of skull-base fractures.  Clinical Radiology. 2005;  60 878-885
• 5 Day J D, Koos W T, Matula C W, Lang J. Color Atlas of Microneurosurgical Approaches. Thieme, Stuttgart, New York 1997
• 6 Dietrich U, Feldges A, Sievers K, Kocks W. Lokalisation von frontobasalen traumatischen Liquorfisteln. Ein Vergleich von radiologischem Befund und Operationsbefund.  Zentralbl Neurochir. 1993;  54 24-31
• 7 Eljamel M S, Pidgeon C N, Toland J, Phillips J B, O’Dwyer A A. MRI cisternography and the localisation of CSF fistulae.  Br J Neurosurg. 1994;  8 433-434
• 8 Friedman J A, Ebersold M J, Quast L M. Post-traumatic cerebrospinal fluid leakage.  World J Surg. 2001;  25 1062-1066
• 9 Georgantopoulou A, Hodgkinson P, Gerber C. Cranial-base surgery: a reconstructive algorithm.  Br J Plast Surg. 2003;  56 10-13
• 10 Greenberg  (Ed) M S. Head trauma. Handbook of neurosurgery. 5th ed. Thieme, Stuttgart 2001; 626-679
• 11 Jennett B, Teasdale G, Fry J, Braakman R, Minderhoud J, Heiden J, Kurze T. Treatment for severe head injury.  J Neurol Neurosurg Psychiatry. 1980;  43 289-295
• 12 Kästner S, Schroth I, Böker D K. Verzögertes Auftreten posttraumatischer Liquorfisteln als Ursache rezidivierender Meningitiden.  Nervenarzt. 2001;  72 307-311
• 13 Katzen J, Jarrahy R, Eby J, Mathiasen R, Margulies D, Shahinian H. Craniofacial and skull base trauma.  J Trauma. 2003;  54 1026-1034
• 14 Kelly J P, Rosenberg J H. Diagnosis and management of concussion in sports.  Neurology. 1997;  48 575-580
• 15 Kessler P, Hardt N. Results of transcranial and subcranial management of fractures of the naso-ethmoid-orbital system in complex midfacial fractures.  Mund Kiefer Gesichtschir. 1998;  2 202-208
• 16 Khatib K, Danino A, Malaka G. The frontal sinus: a culprit or a victim? A review of 40 cases.  J Cranio-Maxillofacial Surg. 2004;  32 314-317
• 17 Kruse J J, Awasthi D. Skull-base trauma: neurosurgical perspective.  J Cranimaxillofac Trauma. 1998;  4 8-14
• 18 Loew F, Pertuiset B, Chaumier E E, Jaschke H. Traumatic, spontaneous and postoperative CSF rhinorrhoea.  Adv Tech Stand Neurosurg. 1984;  11 169-207
• 19 Matula C W, Steiger C N. Hemostasis and Fleece-Bound Sealing in Neurosurgery. Thieme, Stuttgart, New York 2005
• 20 MacKenzie E J, Rice D P. Head injuries: costs and consequences.  J Head Trauma Rehab. 1991;  6 76-91
• 21 Messerklinger W. Nasenendoskopie: Nachweis, Lokalisation und Differentialdiagnose der nasalen Liquorrhoe.  HNO (Berlin). 1972;  20 268-270
• 22 Nihio Y, Hayashi N, Hamada H, Hirashima Y, Endo S. A case of delayed brain abscess due to retained intracranial wooden foreign body: a case report and review of the last 20 years.  Acta Neurochir (Wien). 2004;  146 847-850
• 23 Oberascher G. Diagnostik der Rhinoliquorrhoe.  Eur Arch Otorhinolaryngol. 1993;  3 (Suppl 1) 347-362
• 24 Ponde J M, Metzger P, Amaral G, Machado M, Prandini M. Anatomical variations of the frontal sinus.  Minim Invas Neurosurg. 2003;  46 29-32
• 25 Reilly P L, Adams J, Graham D. Patients with head injuries who talk and die.  Lancet. 1975;  2 375-377
• 26 Reiss M, Reiss G. The value of conventional roentgen imaging and computerized tomography in diagnosis of frontobasal fractures.  Schweiz Rundsch Med Prax. 2000;  89 1243-1247
• 27 Rettinger G, Kalender W. Computertomographie bei Erkrankungen des HNO-Bereiches. II. Hochauflösungs-Computertomographie des Gesichtsschädels.  HNO. 1981;  29 364-369
• 28 Rocchi G, Caroli E, Belli E, Salvati M, Cimatti M, Delfini R. Severe craniofacial fractures with frontobasal involvement and cerebrospinal fluid fistula: indications for surgical repair.  Surg Neurol. 2005;  63 559-564
• 29 Russegger L, Fischer J, Twerdy K. Surgical management of frontobasal defects by a transcranial subfrontal approach.  Zentralbl Neurochirur. 1988;  49 209-297
• 30 Sakas D E, Beale D J, Ameen A A, Whitwell H L, Whittaker K W, Krebs A J, Abbasi K H, Dias P S. Compound anterior cranial base fractures: classification using computerized tomography scanning as basis for selection of patients for dural repair.  J Neurosurg. 1998;  88 471-477
• 31 Samii M, Tatagiba M. Skull base trauma: Diagnosis and management.  Neurol Res. 2002;  24 147-156
• 32 Saul T, Drucker T. Effect of intracranial pressure monitoring and aggressive treatment on mortality in severe head injury.  J Neurosurg. 1982;  56 498-503
• 33 Schneider O, Richter H P. Special aspects in diagnosis and treatment of open craniocerebral injuries including basilar skull fractures.  Unfallchirurg. 1993;  96 591-594
• 34 Stone J A, Castillo M, Neelon B, Mukherji S K. Evaluation of CSF leaks: High resolution CT compared with contrast enhanced CT and radionuclide cisternography.  Am J Neuroradiol. 1999;  20 706-712
• 35 Tosun F, Gonsul E, Yetiser S, Gerek M. Analysis of different surgical approaches for the treatment of cerebrospinal fluid rhinorrhea.  Minim Invas Neurosurg. 2005;  48 355-360
• 36 Wax M K, Ramadan H H, Ortiz O, Wetmore S J. Contemporary management of cerebrospinal fluid rhinorrhoea.  Otolaryngol Head Neck Surg. 1997;  116 442-449
• 37 Yilmazlar S, Arslan E, Kocaeli H, Dogan S, Aksoy K, Korfali E, Doygun M. Cerebrospinal fluid leakage complicating skull base fractures: Analysis of 81 cases.  Neurosurg Rev. 2006;  29 64-71