Extensive traumatic anterior skull base fractures with cerebrospinal fluid leak: classification and repair techniques using combined vascularized tissue flaps

Abstract

OBJECT This article introduces a classification scheme for extensive traumatic anterior skull base fracture to help stratify surgical treatment options. The authors describe their multilayer repair technique for cerebrospinal fluid (CSF) leak resulting from extensive anterior skull base fracture using a combination of laterally pediculated temporalis fascial-pericranial, nasoseptal-pericranial, and anterior pericranial flaps. METHODS Retrospective chart review identified patients treated surgically between January 2004 and May 2014 for anterior skull base fractures with CSF fistulas. All patients were treated with bifrontal craniotomy and received pedicled tissue flaps. Cases were classified according to the extent of fracture: Class I (frontal bone/sinus involvement only); Class II (extent of involvement to ethmoid cribriform plate); and Class III (extent of involvement to sphenoid bone/sinus). Surgical repair techniques were tailored to the types of fractures. Patients were assessed for CSF leak at follow-up. The Fisher exact test was applied to investigate whether the repair techniques were associated with persistent postoperative CSF leak. RESULTS Forty-three patients were identified in this series. Thirty-seven (86%) were male. The patients’ mean age was 33 years (range 11–79 years). The mean overall length of follow-up was 14 months (range 5–45 months). Six fractures were classified as Class I, 8 as Class II, and 29 as Class III. The anterior pericranial flap alone was used in 33 patients (77%). Multiple flaps were used in 10 patients (3 salvage) (28%)—1 with Class II and 9 with Class III fractures. Five (17%) of the 30 patients with Class II or III fractures who received only a single anterior pericranial flap had persistent CSF leak (p < 0.31). No CSF leak was found in patients who received multiple flaps. Although postoperative CSF leak occurred only in high-grade fractures with single anterior flap repair, this finding was not significant. CONCLUSIONS Extensive anterior skull base fractures often require aggressive treatment to provide the greatest long-term functional and cosmetic benefits. Several vascularized tissue flaps can be used, either alone or in combination. Vascularized flaps are an ideal substrate for cranial base repair. Dual and triple flap techniques that combine the use of various anterior, lateral, and nasoseptal flaps allow for a comprehensive arsenal in multilayered skull base repair and salvage therapy for extensive and severe fractures.

Changing the surgical dogma in frontal sinus trauma: transnasal endoscopic repair

“…All patients with posterior table fractures in the current series had CSF leakage. Although the pericranial flap is the workhorse of open anterior skull base reconstruction, it has a 10% to 17% failure rate in the management of traumatic leaks, most likely due to poor visualization at the ethmoid roof. Importantly, 31 (73.8%) subjects with posterior table fractures in this study also had involvement of the anterior skull base (ethmoid roof and cribriform).…”

The Surgical Treatment of Posttraumatic Skull Base Defects with Cerebrospinal Fluid Leak

“…[16][17][18] Central defects or type I defects can easily be repaired by transnasal endoscopic approach, but lateral defects (II), both central and lateral (III) including frontal sinus defects and middle skull base defects (IV), can only be repaired by an open approach. [1][2][3]9,[11][12][13][14]19,[21][22][23] In this study, a strong relation between the location and the surgical approach was achieved, which denies the fact stated by Manuel et al 20 that location is not a predisposing factor for a surgical approach. Also in this study, no other endoscopic approach apart from transnasal endoscopic approach was done.…”

“…Simple skull base defect with CSF leak can be repaired by transnasal endoscopic approach, but compound, depressed, comminuted, and complex type of defect are to be repaired through an open craniotomy approach. [1][2][3][10][11][12][13][14][15] In compound, comminuted, depressed, and complex or mixed type of defect, the realignment, removal, and or fixation of fracture is not possible through an endoscope; therefore, in such cases, open craniotomy is mandatory. Also in this study, the comminuted fractures with very small floating bone fragments were removed, and if the defect is large then trimmed, titanium mesh was used, else titanium plates were used to fix the free bone fragments.…”

Endoscopic Removal of a Bullet in Rosenmuller Fossa: Case Report

“…11 Dual and triple flap techniques that combine various anterior, lateral, and nasoseptal flaps can also be used in extensive and severe cases. 12 Recent studies aimed at understanding CSF leaks originating at the skull base have focused on risks for recurrence postoperatively. Size of dural defect and location of surgery have been found to be important risk factors for CSF leak in skull-base reconstruction using nasoseptal flaps, with dural defects larger than 2.0 cm 2 and surgery to the sella or clivus posing a greater risk.…”