Management of Skull Base Fractures in a UK Major Trauma Centre

Background Fractures of the skull base are a frequent finding in patients with multiple traumatic and intracranial injuries. The sequelae of skull base fractures are often not immediately evident in the acute setting, however can have serious morbidity associated with them and long-term consequences on patients' quality of life. Such complications include vascular injury, CSF leak and cranial nerve injury.

Skull base fractures involving the carotid canals can result in vascular injury leading to long-term complications including stroke and the formation of caroticocavernous fistulas (CCF). This requires endovascular intervention and long-term follow-up. Failure to diagnose vascular injury can result in debilitating symptoms. Skull base fractures resulting in CSF leaks result in an increased risk of meningitis, low pressure symptoms and chronic problems with wound healing.

Our institution is a Major Trauma Centre (MTC) in London's trauma network. As a result, our institution sees ∼3,000 trauma cases per year. To date, there is no consensus on the management of the complications of skull base fracture and little evidence in the literature describing the natural progression and follow-up of this largely young and otherwise healthy patient group. We aim to present our experience of managing traumatic base of skull fractures and our outcomes.

Methods A retrospective case note review was performed of all patients in our trauma database who had radiographic evidence of a base of skull fracture from 2010 to 2017. A total of 800 consecutive cases of skull base fractures were identified and these were classified into their anatomical locations. Evidence of vascular injury, CSF leak or cranial nerve injury were recorded. The mechanism of injury was noted and patients were followed up and interventions and outcomes were documented. Injuries in each of the anterior, middle and posterior fossae were separately analyzed.

Results Between 2010 and 2017, a total of 800 cases were identified that had sustained a traumatic injury to the skull base. 75% of all fractures of the skull base involved the middle cranial fossa. 22% involved injures to the posterior fossa and 15% of cases involved the anterior cranial fossa. Mean age of our patient cohort was 32. Of all documented skull base fractures, only 8% had any evidence of CSF leak, 14% had confirmed vascular injury (although 80% had been investigated for a vascular injury) and only 4% had a cranial nerve deficit. Mean follow-up was 1 year. The commonest cause for mortality in this group was associated concomitant injuries at the time of presentation.

Conclusion There is little reported literature on the long-term outcomes of patients who sustain CSF leak, vascular injury or cranial nerve deficit following a base of skull fracture. In our experience, many of these patients are lost to follow-up and indeed, the nature of this study is limited by its retrospective nature. Further prospective work must be done in this patient group to better understand the history of these patients.