• Users Online: 694
  • Print this page
  • Email this page


 
 
Table of Contents
REVIEW ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 2  |  Page : 93-96

Skull-base fractures: Pearls of etiopathology, approaches, management, and outcome


1 Department of Neurosurgery, National Institute of Mental Health and Neuro-Sciences, Bengaluru, Karnataka, India
2 Centro de Investigaciones Biomédicas, University of Cartagena, Cartagena de Indias, Bogota, Colombia
3 RED LATINO, Organización Latinoamericana de Trauma y Cuidado Neurointensivo, Bogota, Colombia
4 Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
5 Department of Anesthesia, Narayana Medical College Hospital, Nellore, Andhra Pradesh, India
6 Department of Community Medicine, MGM Medical College and LSK Hospital, Kishanganj, Bihar, India
7 Department of Neurosurgery, Narayana Medical College Hospital, Nellore, Andhra Pradesh, India

Date of Submission19-Mar-2019
Date of Acceptance01-May-2019
Date of Web Publication19-Jun-2019

Correspondence Address:
Amit Agrawal
Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddy Palem, Nellore - 524 003, Andhra Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_12_19

Rights and Permissions
  Abstract 


Fractures involving skull bases usually results from high-velocity impacts, i.e., motor vehicular accidents. The estimated incidence of skull-base fracture varies from 4% of all head injuries to 7%–16% of closed head injuries. Many studies have emphasized the importance of the management of basal skull fractures as it can be associated with major neurological deficits, can carry a risk of being missed during clinical evaluation in a busy emergency room and can additionally lead to life-threatening complications including cerebrospinal fluid (CSF) leak and meningitis. In addition to the bony injuries, skull-base fractures can be accompanied by injury to cranial nerves, intracranial blood vessels, and CSF rhinorrhea or otorrhea (particularly fractures involving anterior and middle cranial fossa). In the presence of characteristics clinical features, patient should be thoroughly clinical examination and pertinent investigation with appropriate imaging modality for the presence of additional intracranial lesions and as delayed diagnosis can lead to increase in neurological morbidity and also rarely mortality.

Keywords: Cranial base, investigation, management, outcome, skull-base fracture, traumatic brain injury


How to cite this article:
Narasinga Rao K V, Said PZH, Moscote-Salazar LR, Satyarthee GD, Kumar V A, Pal R, Agrawal A. Skull-base fractures: Pearls of etiopathology, approaches, management, and outcome. Apollo Med 2019;16:93-6

How to cite this URL:
Narasinga Rao K V, Said PZH, Moscote-Salazar LR, Satyarthee GD, Kumar V A, Pal R, Agrawal A. Skull-base fractures: Pearls of etiopathology, approaches, management, and outcome. Apollo Med [serial online] 2019 [cited 2019 Dec 12];16:93-6. Available from: http://www.apollomedicine.org/text.asp?2019/16/2/93/260681




  Introduction Top


Rising incidence of road traffic accident has resulted in the significantly increased risk for sustaining traumatic brain injury globally.[1],[2],[3] Severe head injury is associated with poorer neurological outcome and may harbor other injuries which need neurosurgical intervention including traumatic intracranial hemorrhages, for example, extradural hematoma, subdural hematoma, intracerebral hematoma, depressed skull fractures, and associated facial injuries.[4],[5] Recently, many studies emphasized the importance of proper and early diagnosis and prompt management of basal skull fractures as usually associated with major neurological deficits and can be easily overlooked and missed in a busy emergency setup and missed or delayed diagnosis carry life-threatening squeal of meningitis, ventriculitis, and intracranial abscess.[6],[7],[8] In the present review, authors describe the various etiological factors, clinical features, investigations, and pertinent management approaches involving basal skull fractures and pertinent literature is briefly reviewed.


  Incidence Top


The estimated incidence of skull-base fracture is highly variable and can vary from 4% of all head injuries[9],[10] to 7%–16% of closed head injuries.[11] In the majority of the cases (up to 90%) are caused due to closed head injuries, while other causes include penetrating injuries.[12],[13] Anterior fossa fractures are represents the most common (50%) and occipital bones (30%) and temporal bone fractures (20%).[14] However, Yellinek et al. observed, the most common site of fracture was temporal bone (30%), followed by occipital (20%), and frontal bones (17%)[8] with an incidence of multiple fractures was 13%.[8] Basal skull fractures can also be associated with traumatic intracranial lesions including subarachnoid hemorrhage, intracerebral hemorrhages, and diffuse axonal injury.[8] In addition to the bony injuries, skull-base fractures can be accompanied by injury to multiple cranial nerves, intracranial arteries, and venous sinuses and CSF rhinorrhea or otorrhea (particularly fractures involving anterior and middle cranial fossa).[15],[16] Fractures involving clivus are usually regarded as fatal and carry a poor prognosis.[17],[18]


  Etiopathology Top


Skull base fractures are usually caused due to high-velocity impact (e.g., motor vehicular accidents), these can be of linear or comminuted, closed, or compound variety externally or internally.[11],[19] To facilitate our anatomical and pathological understating the skull base can be divided into anterior, middle, and posterior cranial fossa, respectively.[20] Anterior cranial fossa consists of paranasal sinuses, cribriform plate, and orbital roof, while the middle cranial fossa consists of the sphenoid bone and temporal bone and the posterior cranial fossa consists of clivus, condyle, and part of petrous temporal and occipital bones.[20] These cranial fossa contain delicate neural and vascular structures, and skull base foramina usually transmit various cranial nerves and associated vessels.[19] Uneven internal surfaces, sharp bony edges and the presence of dural folds increases the vulnerability of intracerebral and neurovascular structures more vulnerable to injuries.[21],[22] The frontotemporal lobes of the brain are considered as most vulnerable regions to injuries are as exposed to sharp bony and tentorial edges.[23]


  Anterior Cranial Base Fractures Top


Anatomically structures involved in the anterior cranial base fractures include posterior wall of the frontal sinus, the roof of anterior and posterior ethmoid cells, cribriform–ethmoid junction, and the orbital roof.[24] Clinically, the fracture of the anterior cranial base can be suspected due to the presence of CSF rhinorrhea, periorbital ecchymosis (Raccoon's eyes), loss of smell, and impairment in vision due to the damage to optic nerves or orbital structures).[11],[24],[25]


  Temporal Bone Fractures Top


The temporal bone is one of the most common locations for basal skull fractures and can be classified as transverse or longitudinal (the axis of fracture in reference to petrous ridge) or otic capsule sparing or violating.[26] Longitudinal fractures of the temporal bone are considered relatively more common (80%–90%) than transverse fractures (10%–20%) and in 8%–10% of cases may harbor combination of injuries.[27] CSF rhinorrhea is more common findings associated with longitudinal temporal bone fractures, while sensorineural hearing loss is more common with transverse temporal bone fractures.[26],[27]


  Sphenoid Bone Top


Fractures of the sphenoid bone can involve either alone or in combinations including fractures of sphenoid sinus, sella turcica, upper clivus, greater wing and/or lesser wing, and pterygoid process.[28],[29] Fractures of the sphenoid bone can lead to CSF rhinorrhea, cranial nerves (III, IV, and VI) injuries with resultant ophthalmoplegia, and may have associated injury to the optic nerve, or optic chiasm, sellar fractures with endocrine dysfunctions or injury to the internal carotid artery with sequel.[12],[29]


  Neurovascular Injuries Top


Up to 50% of cases may have associated vascular injuries in patients with suspected to harbor basal skull. However, majority of cases may remain asymptomatic without much clinical sequel.[10],[30],[31] The pathological spectrum of injuries includes transection, dissection, thrombosis, incarceration, and development of pseudoaneurysm formation or arteriovenous fistula.[32],[33]


  Clinical Features Top


A careful and detailed examination of the patient with a high index of clinical suspicion is the most important initial step to confirm the presence of skull base fractures and a possible site of involvement. These patients can present with the loss of consciousness, headache, pneumocephalus, CSF rhinorrhea or otorrhea, facial swelling, deformity, dysfunctions of cranial nerve, and features suggestive of intracranial mass lesions including the focal neurological deficit, for example, motor weakness or seizures.[8],[34] In cases of anterior skull base fractures, patient may complain of loss of smell (olfactory nerve injury), CSF leak (fracture of the cribriform plate), visual impairment (optic nerve injury), and peri-orbital ecchymosis.[35]

The temporal bone fractures can present with CSF otorrhea, hearing loss, vestibular dysfunction, and facial nerve weakness.[28] Special attention is needed to suspect vascular injuries, particularly in the presence of cervical spine injuries (i.e., subluxations); fractures involving foramen transversarium, hyperextension or hyperflexion injury mechanism, presence of anisocoria or Horner syndrome, bleeding from the ear, nose, or mouth, and unexplained lateralizing signs, skull-base fractures which are in the vicinity of major cranial arteries and fractures involving petrous temporal.[32],[36],[37]


  Imaging Findings Top


Plain X-rays of the skull (anterior-posterior, lateral, and basal projections) may delineate the site of fractures and presence of any foreign bodies. However, the wider availability of computed tomography (CT) scan has replaced their use both in diagnosis and management planning.[38],[39],[40] A high-resolution cranial CT scan with thin sections of the brain with bone window can help to ascertain the diagnosis including the extent of fractures or any associated intracranial injuries.[6],[19] Helical CT has been widely used to investigate the skull-base fractures as the images obtained can be reconstructed in 3D manner.[41],[42] Apart from the direct visualization of the fracture lines, presence of pneumocephalus, subcutaneous emphysema, and air-fluid levels in the sinuses can act as indirect pointer of suspected skull-base fractures.[38] While interpreting the images, extra care is needed as normal suture lines may be mistaken for fractures.[28] Traumatic sutural diastases may require imaging with multiplanar imaging with 3D cranial skull base reconstruction.[43] Posttraumatic CSF rhinorrhea may need to be further investigated with magnetic resonance (MR) imaging study (or CT cisternography to locate the site of the leak and to plan surgical intervention.[19],[25] In suspected cases of vascular structures can be investigated with CT of MR angiography or if necessary, a conventional digital subtraction angiography can be performed.[33],[44]


  Management Top


The basic management includes the management of airway, breathing, and circulation. Specific management of skull-base fractures depends on the location, extent, type of injury closed versus open, linear versus comminuted, associated intracranial injuries, or any associated injuries to the neural and vascular structures. Penetrating skull base injuries needs careful attention to estimate the extent of injuries and the presence of any foreign bodies and even angiography is also considered.[45],[46]


  Prophylactic Antibiotics Top


The role of prophylactic antibiotics in these patients remains still controversial as few authors have suggested using prophylactic antibiotics, particularly in patients with CSF leak.[47] However, other authors questioned the role of prophylactic antibiotics and recommended against the use of prophylactic antibiotics.[8],[48],[49] Due to lack of studies and small number of patients reported the role of prophylactic in penetrating skull-base injuries is largely unclear.[50],[51]


  Surgical Management Top


The surgery of skull-base fracture aims for restoration the normal anatomy, reconstruction of the skull base, to avoid complications (i.e., prevention of CSF leak), evacuation of any intracranial mass lesions (i.e., contusion, hematomas), repair of damaged sinuses and removal of foreign bodies and debris.[28],[52],[53] Details of indications and various surgical methods, approaches and techniques can be found elsewhere in the literature.[54],[55],[56] In majority of the patients (up to 85%) posttraumatic rhinorrhea usually respond well to conservative management with absolute best rest, head end elevation).[57],[58] Those patients' who fails to conservative management may need surgical intervention to close the site of leak.[57],[59]


  Conclusions Top


Fractures involving skull bases usually results from high velocity impacts, i.e., motor vehicular accidents. In the presence of characteristics clinical features one should investigate the patient with appropriate imaging modality as the presence of intracranial lesions and delayed diagnosis can lead to increase in morbidity and mortality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Agrawal A, Savardekar A, Singh M, Pal R, Shukla DP, Rubiano AM, et al. Pattern of reporting and practices for the management of traumatic brain injury: An overview of published literature from India. Neurol India 2018;66:976-1002.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Dewan MC, Rattani A, Gupta S, Baticulon RE, Hung YC, Punchak M, et al. Estimating the global incidence of traumatic brain injury. J Neurosurg 2018;128:1-8.  Back to cited text no. 2
    
3.
Massenburg BB, Veetil DK, Raykar NP, Agrawal A, Roy N, Gerdin M. A systematic review of quantitative research on traumatic brain injury in India. Neurol India 2017;65:305-14.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Chan KH, Mann KS, Yue CP, Fan YW, Cheung M. The significance of skull fracture in acute traumatic intracranial hematomas in adolescents: A prospective study. J Neurosurg 1990;72:189-94.  Back to cited text no. 4
    
5.
Levi L, Guilburd JN, Linn S, Feinsod M. The association between skull fracture, intracranial pathology and outcome in pediatric head injury. Br J Neurosurg 1991;5:617-25.  Back to cited text no. 5
    
6.
Sivanandapanicker J, Nagar M, Kutty R, Sunilkumar BS, Peethambaran A, Rajmohan BP, et al. Analysis and clinical importance of skull base fractures in adult patients with traumatic brain injury. J Neurosci Rural Pract 2018;9:370-5.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Ratilal BO, Costa J, Pappamikail L, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database of Systematic Reviews 2015;(4):CD004884. DOI: 10.1002/14651858.CD004884.pub4.  Back to cited text no. 7
    
8.
Yellinek S, Cohen A, Merkin V, Shelef I, Benifla M. Clinical significance of skull base fracture in patients after traumatic brain injury. J Clin Neurosci 2016;25:111-5.  Back to cited text no. 8
    
9.
Chee CP, Ali A. Basal skull fractures. A prospective study of 100 consecutive admissions. Aust N Z J Surg 1991;61:597-602.  Back to cited text no. 9
    
10.
Katzen JT, Jarrahy R, Eby JB, Mathiasen RA, Margulies DR, Shahinian HK. Craniofacial and skull base trauma. J Trauma 2003;54:1026-34.  Back to cited text no. 10
    
11.
Yilmazlar S, Arslan E, Kocaeli H, Dogan S, Aksoy K, Korfali E, et al. Cerebrospinal fluid leakage complicating skull base fractures: Analysis of 81 cases. Neurosurg Rev 2006;29:64-71.  Back to cited text no. 11
    
12.
Samii M, Tatagiba M. Skull base trauma: Diagnosis and management. Neurol Res 2002;24:147-56.  Back to cited text no. 12
    
13.
Legros B, Fournier P, Chiaroni P, Ritz O, Fusciardi J. Basal fracture of the skull and lower (IX, X, XI, XII) cranial nerves palsy: Four case reports including two fractures of the occipital condyle – A literature review. J Trauma 2000;48:342-8.  Back to cited text no. 13
    
14.
Kerman M, Cirak B, Dagtekin A. Management of skull base fractures. Neurosurg Q 2002;12:23-41.  Back to cited text no. 14
    
15.
Rivkin MA, Saraiya PV, Woodrow SI. Sinovenous thrombosis associated with skull fracture in the setting of blunt head trauma. Acta Neurochir (Wien) 2014;156:999-1007.  Back to cited text no. 15
    
16.
Sonig A, Thakur JD, Chittiboina P, Khan IS, Nanda A. Is posttraumatic cerebrospinal fluid fistula a predictor of posttraumatic meningitis? A US nationwide inpatient sample database study. Neurosurg Focus 2012;32:E4.  Back to cited text no. 16
    
17.
Joslyn JN, Mirvis SE, Markowitz B. Complex fractures of the clivus: Diagnosis with CT and clinical outcome in 11 patients. Radiology 1988;166:817-21.  Back to cited text no. 17
    
18.
Menkü A, Koç RK, Tucer B, Durak AC, Akdemir H. Clivus fractures: Clinical presentations and courses. Neurosurg Rev 2004;27:194-8.  Back to cited text no. 18
    
19.
Baugnon KL, Hudgins PA. Skull base fractures and their complications. Neuroimaging Clin N Am 2014;24:439-65, vii-viii.  Back to cited text no. 19
    
20.
Abrahams PH, McMinn RMH, Hutchings RT, Marks SC. McMinn's Color Atlas of Human Anatomy. 5th ed. New York: Mosby, Edinburgh; 2003.  Back to cited text no. 20
    
21.
Bayley PJ, Gold JJ, Hopkins RO, Squire LR. The neuroanatomy of remote memory. Neuron 2005;46:799-810.  Back to cited text no. 21
    
22.
Tong KA, Ashwal S, Holshouser BA, Nickerson JP, Wall CJ, Shutter LA, et al. Diffuse axonal injury in children: Clinical correlation with hemorrhagic lesions. Ann Neurol 2004;56:36-50.  Back to cited text no. 22
    
23.
Scheid R, Preul C, Gruber O, Wiggins C, von Cramon DY. Diffuse axonal injury associated with chronic traumatic brain injury: Evidence from T2*-weighted gradient-echo imaging at 3 T. AJNR Am J Neuroradiol 2003;24:1049-56.  Back to cited text no. 23
    
24.
Kienstra MA, Van Loveren H. Anterior skull base fractures. Facial Plast Surg 2005;21:180-6.  Back to cited text no. 24
    
25.
Schuknecht B, Graetz K. Radiologic assessment of maxillofacial, mandibular, and skull base trauma. Eur Radiol 2005;15:560-8.  Back to cited text no. 25
    
26.
Ishman SL, Friedland DR. Temporal bone fractures: Traditional classification and clinical relevance. Laryngoscope 2004;114:1734-41.  Back to cited text no. 26
    
27.
Cannon CR, Jahrsdoerfer RA. Temporal bone fractures. Review of 90 cases. Arch Otolaryngol 1983;109:285-8.  Back to cited text no. 27
    
28.
Wani AA, Ramzan AU, Raina T, Malik NK, Nizami FA, Qayoom A, et al. Skull base fractures: An institutional experience with review of literature. Indian J Neurotrauma 2013;10:120-6.  Back to cited text no. 28
    
29.
Unger JM, Gentry LR, Grossman JE. Sphenoid fractures: Prevalence, sites, and significance. Radiology 1990;175:175-80.  Back to cited text no. 29
    
30.
Liu CC, Wang CY, Shih HC, Wen YS, Wu JJ, Huang CI, et al. Prognostic factors for mortality following falls from height. Injury 2009;40:595-7.  Back to cited text no. 30
    
31.
Yildirim A, Gurelik M, Gumus C, Kunt T. Fracture of skull base with delayed multiple cranial nerve palsies. Pediatr Emerg Care 2005;21:440-2.  Back to cited text no. 31
    
32.
McKevitt EC, Kirkpatrick AW, Vertesi L, Granger R, Simons RK. Identifying patients at risk for intracranial and extracranial blunt carotid injuries. Am J Surg 2002;183:566-70.  Back to cited text no. 32
    
33.
Miller PR, Fabian TC, Bee TK, Timmons S, Chamsuddin A, Finkle R, et al. Blunt cerebrovascular injuries: Diagnosis and treatment. J Trauma 2001;51:279-85.  Back to cited text no. 33
    
34.
Lin DT, Lin AC. Surgical treatment of traumatic injuries of the cranial base. Otolaryngol Clin North Am 2013;46:749-57.  Back to cited text no. 34
    
35.
Jimenez DF, Sundrani S, Barone CM. Posttraumatic anosmia in craniofacial trauma. J Craniomaxillofac Trauma 1997;3:8-15.  Back to cited text no. 35
    
36.
Kerwin AJ, Bynoe RP, Murray J, Hudson ER, Close TP, Gifford RR, et al. Liberalized screening for blunt carotid and vertebral artery injuries is justified. J Trauma 2001;51:308-14.  Back to cited text no. 36
    
37.
Willis BK, Greiner F, Orrison WW, Benzel EC. The incidence of vertebral artery injury after midcervical spine fracture or subluxation. Neurosurgery 1994;34:435-41.  Back to cited text no. 37
    
38.
Choi YY, Hyun DK, Park HC, Park CO. Pneumocephalus in the absence of craniofacial skull base fracture. J Trauma 2009;66:E24-7.  Back to cited text no. 38
    
39.
Connor SE, Tan G, Fernando R, Chaudhury N. Computed tomography pseudofractures of the mid face and skull base. Clin Radiol 2005;60:1268-79.  Back to cited text no. 39
    
40.
Eisenberg HM, Gary HE Jr., Aldrich EF, Saydjari C, Turner B, Foulkes MA, et al. Initial CT findings in 753 patients with severe head injury. A report from the NIH traumatic coma data bank. J Neurosurg 1990;73:688-98.  Back to cited text no. 40
    
41.
Fatterpekar GM, Doshi AH, Dugar M, Delman BN, Naidich TP, Som PM. Role of 3D CT in the evaluation of the temporal bone. Radiographics 2006;26 Suppl 1:S117-32.  Back to cited text no. 41
    
42.
Ringl H, Schernthaner RE, Schueller G, Balassy C, Kienzl D, Botosaneanu A, et al. The skull unfolded: A cranial CT visualization algorithm for fast and easy detection of skull fractures. Radiology 2010;255:553-62.  Back to cited text no. 42
    
43.
Connor SE, Flis C. The contribution of high-resolution multiplanar reformats of the skull base to the detection of skull-base fractures. Clin Radiol 2005;60:878-85.  Back to cited text no. 43
    
44.
Stolzmann P, Winklhofer S, Schwendener N, Alkadhi H, Thali MJ, Ruder TD. Monoenergetic computed tomography reconstructions reduce beam hardening artifacts from dental restorations. Forensic Sci Med Pathol 2013;9:327-32.  Back to cited text no. 44
    
45.
Agrawal A, Pratap A, Agrawal CS, Kumar A, Rupakheti S. Transorbital orbitocranial penetrating injury due to bicycle brake handle in a child. Pediatr Neurosurg 2007;43:498-500.  Back to cited text no. 45
    
46.
Chowdhury FH, Haque MR, Hossain Z, Chowdhury NK, Alam SM, Sarker MH. Nonmissile penetrating injury to the head: Experience with 17 cases. World Neurosurg 2016;94:529-43.  Back to cited text no. 46
    
47.
Demetriades D, Charalambides D, Lakhoo M, Pantanowitz D. Role of prophylactic antibiotics in open and basilar fractures of the skull: A randomized study. Injury 1992;23:377-80.  Back to cited text no. 47
    
48.
Rimmer J, Belk C, Lund VJ, Swift A, White P. Immunisations and antibiotics in patients with anterior skull base cerebrospinal fluid leaks. J Laryngol Otol 2014;128:626-9.  Back to cited text no. 48
    
49.
Nellis JC, Kesser BW, Park SS. What is the efficacy of prophylactic antibiotics in basilar skull fractures? Laryngoscope 2014;124:8-9.  Back to cited text no. 49
    
50.
Schreckinger M, Orringer D, Thompson BG, La Marca F, Sagher O. Transorbital penetrating injury: Case series, review of the literature, and proposed management algorithm. J Neurosurg 2011;114:53-61.  Back to cited text no. 50
    
51.
Sweeney JM, Lebovitz JJ, Eller JL, Coppens JR, Bucholz RD, Abdulrauf SI. Management of nonmissile penetrating brain injuries: A description of three cases and review of the literature. Skull Base Rep 2011;1:39-46.  Back to cited text no. 51
    
52.
Zhang D, Chen J, Han K, Yu M, Hou L. Management of penetrating skull base injury: A single institutional experience and review of the literature. Biomed Res Int 2017;2017:2838167.  Back to cited text no. 52
    
53.
Arslan M, Eseoǧlu M, Güdü BO, Demir I. Transorbital orbitocranial penetrating injury caused by a metal bar. J Neurosci Rural Pract 2012;3:178-81.  Back to cited text no. 53
[PUBMED]  [Full text]  
54.
Liu P, Wu S, Li Z, Wang B. Surgical strategy for cerebrospinal fluid rhinorrhea repair. Neurosurgery 2010;66:281-5.  Back to cited text no. 54
    
55.
Locatelli D, Rampa F, Acchiardi I, Bignami M, De Bernardi F, Castelnuovo P. Endoscopic endonasal approaches for repair of cerebrospinal fluid leaks: Nine-year experience. Neurosurgery 2006;58(4 Suppl 2):ONS-246-56; discussion ONS-256-7.  Back to cited text no. 55
    
56.
McCormack B, Cooper PR, Persky M, Rothstein S. Extracranial repair of cerebrospinal fluid fistulas: Technique and results in 37 patients. Neurosurgery 1990;27:412-7.  Back to cited text no. 56
    
57.
Bell RB, Dierks EJ, Homer L, Potter BE. Management of cerebrospinal fluid leak associated with craniomaxillofacial trauma. J Oral Maxillofac Surg 2004;62:676-84.  Back to cited text no. 57
    
58.
Savva A, Taylor MJ, Beatty CW. Management of cerebrospinal fluid leaks involving the temporal bone: Report on 92 patients. Laryngoscope 2003;113:50-6.  Back to cited text no. 58
    
59.
Ziu M, Savage JG, Jimenez DF. Diagnosis and treatment of cerebrospinal fluid rhinorrhea following accidental traumatic anterior skull base fractures. Neurosurg Focus 2012;32:E3.  Back to cited text no. 59
    




 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Incidence
Etiopathology
Anterior Cranial...
Temporal Bone Fr...
Sphenoid Bone
Neurovascular In...
Clinical Features
Imaging Findings
Management
Prophylactic Ant...
Surgical Management
Conclusions
References

 Article Access Statistics
    Viewed352    
    Printed52    
    Emailed0    
    PDF Downloaded55    
    Comments [Add]    

Recommend this journal