Surgical Management of Anterior Cranial Base Fractures With Cerebrospinal Fluid Fistulae

Abstract

The closure of CSF fistulae after an anterior cranial base fracture via a combined intracranial extradural and intradural approach, which allows the visualization and repair of the entire anterior base, is safe and effective. It is essentially indicated for patients with extensive bone defects in the cranial base, multiple fractures of the ethmoid bone and the posterior wall of the frontal sinus, cranial nerve involvement, associated lesions necessitating surgery such as intracranial hematomas, and post-traumatic intracranial infection. Rhinorrhea caused by a precisely located small tear may be treated with endoscopy.

Late Onset Cerebrospinal Fluid Leakage Associated With Past Head Injury

“…Conversely, large cranial base fractures necessitate surgical treatment via a bifrontal intracranial approach, because they are almost always associated with extensive dural tears and cerebral injury. 12) The dural defect can be closed with pericranium, fascia lata, or temporalis fascia and fibrin glue as a sealant. Viable pedicled flaps, such as the epicranium, as used in our series, have great advantages over free grafts.…”

“…Pedicled flaps are resistant to infection and are integrated more rapidly than free flaps into the recipient site, providing immediate watertight closure, as has been well documented. 12,14) We propose that bilateral craniotomy is better, even if radiological studies show unilateral dural defects, because dural tears on the contralateral side are not rare, and both olfactory bulbs may be injured. 11) Therefore, in our cases, we used an intradural approach and repaired the dural defect with viable pedicled flaps, such as galea aponeurotica periosteum or temporoparietal fascial flap.…”

Purely Endoscopic Repair of Traumatic Cerebrospinal Fluid Rhinorrhea From the Anterior Skull Base -Case Report-

“…Both transcranial and transnasal approaches have been adopted for the surgical treatment of post-traumatic rhinorrhea. 18,20,22) The widespread application of endoscopic endonasal techniques extending beyond the sellar region 2,4,11) has recently led neurosurgeons and otorhinolaryngological surgeons to advocate this technique as a possible treatment option for CSF leaks. 5,6,15,18,22) We report a case of traumatic ethmoidal leak that was successfully treated using a purely endoscopic endonasal method.…”

Surgical anatomy and utility of pedicled vascularized tissue flaps for multilayered repair of skull base defects

“…3 However, various problems with this flap have been identified, and 10%-17% of patients have persistent CSF leaks after initial repair, which suggests flap failure. 10,13,34 Furthermore, the length of the anteriorly based pericranium is limited and has a limited arc of rotation that reduces the versatility of this flap. Trauma to the anterior forehead (comminuted fractures, radiation treatment, and extensive tumors) may compromise the vascular supply from the supraorbital and supratrochlear arteries, potentially obviating this flap design in some cases.…”