Analysis and Clinical Importance of Skull Base Fractures in Adult Patients with Traumatic Brain Injury

Abstract

Aims and Objectives:Basal skull fracture (BSF) is rare in head injury (HI) patients and occasionally goes unnoticed which may lead to cerebrospinal fluid (CSF) fistula. With changing trends in HI, there is a need to reassess incidence and pattern of BSF pattern, CSF leak, meningitis, and management protocol, especially in this part of the world where detailed literature is lacking.Subjects and Methods:We closely followed adult patients admitted with BSF in our institute between January 2013 and December 2014. Associated clinical features were recorded. In case of CSF leak, detailed CSF study was done and patients were managed accordingly. Patients with persistent CSF leak were managed surgically.Results:During the study period, 194 of 5041 HI patients had evidence of BSF (3.85%). BSF was most commonly associated with moderate-to-severe HI (73.19%). About 81.44% patients were male and 29.9% were <30 years. Most common cause was road traffic accident (84.54%). Isolated anterior cranial fossa (ACF) fracture was most common (50%). About 63.92% patients had raccoon eyes. Forty-three patients had CSF leak with CSF rhinorrhea being more common. Culture of only 5 patients suggested bacterial meningitis. CSF leak lasted for more than 10 days in 8 patients, of which 4 patients required surgical repair.Conclusions:BSF is rare in victims of HI. It is more common in young adult males. ACF fractures are most common in our setup. Clinical signs of BSF are supportive but not definitive; high resolution computed tomography head is gold standard to detect BSF. CSF leak is rare and most of the cases can be managed conservatively. Leak persisting more than 7–10 days has high risk of developing meningitis and likely to need surgical intervention.

Prevalence and pattern of basal skull fracture in head injury patients in an academic hospital

“…Notably, these cohort characteristics are consistent with those in previous studies. 4,6,8 A striking contrast between these studies and ours is that while the former have consistently shown vehicle-related accidents to be the most common aetiology of traumatic head injuries, our study found assault to be the highest cause, accounting for 46% (98/210) of all cases of traumatic head injury evaluated. This finding implies that there were high levels of interpersonal violence in this study population, despite a survey by Statistics South Africa reporting a moderate decline in assault cases between 2013 and 2017.…”

“…The predominance of MCF fractures is thought to be because of the presence of neurovascular foramina (which are presumed to be points of structural weakness) and thin bones in the MCF, which render it susceptible to fractures in comparison with the anterior and posterior compartments. 4,6 Furthermore, the site of impact in the case of head injury tends to be from the sides or front. 2…”

“…3,5,8 In most studies, the underlying mechanism of injury has been consistently reported to be road accidents, a phenomenon that can be attributed to various factors depending on geographic location. 3,6,11…”

“…Some of the known clinical signs of BSF include racoon eye, rhinorrhoea, rhinorrhagia, anosmia, visual impairment, otorrhoea, otorrhagia, hearing loss, neurovascular injuries, Battle sign, phonation problems, vocal cord paralysis and/or aspiration. 4,6,14 It is important to note that if a CSF leak secondary to BSF is missed, it may lead to meningitis and, ultimately, death. 14–17 Identification of these clinical signs in the setting of trauma should always prompt the treating clinician to arrange for an urgent computed tomography (CT) scan of the brain or make a referral to a centre with CT scan facilities for early diagnosis and management so that complications can be avoided.…”

Risks, costs, and outcomes of cerebrospinal fluid leaks after pediatric skull fractures: a MarketScan analysis between 2007 and 2015

“…13,16 Although CSF leaks are known to occur after skull fractures in a minority of cases, precise risk estimates in the pediatric population are extremely limited, 1,16 and our current understanding derives from single-institution studies of skull base injuries. 13,20,24,27,28 In this study, we used the MarketScan database between 2007 and 2015 to assemble a large cohort of pediatric patients with skull fractures. We examined the characteristics and clinical outcomes of pediatric skull fracture patients with and without CSF leaks, and we longitudinally assessed the healthcare costs associated with the care of these patients.…”