Fractures of the Anterior Skull Base Associated with CSF Leak

Abstract

Background: Fractures of the anterior skull base with or without cerebrospinal fluid (CSF) leak still remain a therapeutic challenge and are topic of controversial discussions. Clear strategic and therapeutic concepts are still lacking. Clinical Findings: A simple, but effective classification system has been created similar to the Glasgow Coma Scale to provide a useful patient selection. Diagnostics: Besides a neurological examination some clinical adjunctive possibilities are recommended, such as, for example, the Valsalva manoeuvre, use of a glucose test strip, or the presence of a double ring sign; also a beta-2-transferrin test and intrathecal fluorescent application are possibly useful. Initial CT scans and non-contrast high-resolution CT with 1 mm slices are standard examinations. MRI scans are recommended for delayed brain abscess or meningitis. Surgical Strategies: Patients with acute surgical indications require immediate operation. Patients without acute indications should be operated within 14 days after clinical stabilization. Patients with persistent CSF leak or a chronic brain abscess/meningitis should be operated after special diagnosis and observation. No operation is indicated for patients without clinical rhinorrhoea and just tiny air bubbles in the CT scan or a CSF leak for less than 5 days. All patients need antibiotic protection for about 5 to 10 days. The additional use of lumbar drainage is highly recommended. Surgical Technique: A pediculated galea/periosteal flap for reconstruction, an uni- or sometimes bifrontal craniotomy and, above all, intradural microsurgical techniques are fundamental for a successful surgical outcome. Conclusions: Only a close interdisciplinary cooperation between diagnostics, surgery, ICU and rehabilitation provide favourable clinical results.

Anterior skull base fracture - CSF leak - traumatic brain injury

References

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