|Year : 2019 | Volume
| Issue : 2 | Page : 93-96
Skull-base fractures: Pearls of etiopathology, approaches, management, and outcome
K V. L Narasinga Rao1, Padilla-Zambrano Huber Said2, Luis Rafael Moscote-Salazar3, Guru Duatta Satyarthee4, V Anil Kumar5, Ranabir Pal6, Amit Agrawal7
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 Submission||19-Mar-2019|
|Date of Acceptance||01-May-2019|
|Date of Web Publication||19-Jun-2019|
Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddy Palem, Nellore - 524 003, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
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 Aug 18];16:93-6. Available from: http://www.apollomedicine.org/text.asp?2019/16/2/93/260681
| Introduction|| |
Rising incidence of road traffic accident has resulted in the significantly increased risk for sustaining traumatic brain injury globally.,, 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., 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.,, 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|| |
The estimated incidence of skull-base fracture is highly variable and can vary from 4% of all head injuries, to 7%–16% of closed head injuries. In the majority of the cases (up to 90%) are caused due to closed head injuries, while other causes include penetrating injuries., Anterior fossa fractures are represents the most common (50%) and occipital bones (30%) and temporal bone fractures (20%). However, Yellinek et al. observed, the most common site of fracture was temporal bone (30%), followed by occipital (20%), and frontal bones (17%) with an incidence of multiple fractures was 13%. Basal skull fractures can also be associated with traumatic intracranial lesions including subarachnoid hemorrhage, intracerebral hemorrhages, and diffuse axonal injury. 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)., Fractures involving clivus are usually regarded as fatal and carry a poor prognosis.,
| Etiopathology|| |
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., To facilitate our anatomical and pathological understating the skull base can be divided into anterior, middle, and posterior cranial fossa, respectively. 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. These cranial fossa contain delicate neural and vascular structures, and skull base foramina usually transmit various cranial nerves and associated vessels. Uneven internal surfaces, sharp bony edges and the presence of dural folds increases the vulnerability of intracerebral and neurovascular structures more vulnerable to injuries., The frontotemporal lobes of the brain are considered as most vulnerable regions to injuries are as exposed to sharp bony and tentorial edges.
| Anterior Cranial Base Fractures|| |
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. 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).,,
| Temporal Bone Fractures|| |
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. 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. CSF rhinorrhea is more common findings associated with longitudinal temporal bone fractures, while sensorineural hearing loss is more common with transverse temporal bone fractures.,
| Sphenoid Bone|| |
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., 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.,
| Neurovascular Injuries|| |
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.,, The pathological spectrum of injuries includes transection, dissection, thrombosis, incarceration, and development of pseudoaneurysm formation or arteriovenous fistula.,
| Clinical Features|| |
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., 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.
The temporal bone fractures can present with CSF otorrhea, hearing loss, vestibular dysfunction, and facial nerve weakness. 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.,,
| Imaging Findings|| |
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.,, 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., Helical CT has been widely used to investigate the skull-base fractures as the images obtained can be reconstructed in 3D manner., 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. While interpreting the images, extra care is needed as normal suture lines may be mistaken for fractures. Traumatic sutural diastases may require imaging with multiplanar imaging with 3D cranial skull base reconstruction. 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., 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.,
| Management|| |
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.,
| Prophylactic Antibiotics|| |
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. However, other authors questioned the role of prophylactic antibiotics and recommended against the use of prophylactic antibiotics.,, Due to lack of studies and small number of patients reported the role of prophylactic in penetrating skull-base injuries is largely unclear.,
| Surgical Management|| |
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.,, Details of indications and various surgical methods, approaches and techniques can be found elsewhere in the literature.,, In majority of the patients (up to 85%) posttraumatic rhinorrhea usually respond well to conservative management with absolute best rest, head end elevation)., Those patients' who fails to conservative management may need surgical intervention to close the site of leak.,
| Conclusions|| |
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.
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Conflicts of interest
There are no conflicts of interest.
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