Skull Base fractures ( PDFDrive ).pdf

Basilar Skull Fractures
Leonel Martinez, M.D.
Faculty Advisor: Farrah Siddiqui, M.D.
The University of Texas Medical Branch
Department of Otolaryngology
Grand Rounds Presentation
December 11, 2013
http://vi.sualize.us/tumblr_blood_pography_head_paint_picture_2qxb.html

 Incidence- overall
 Anatomy- Each section
 Evaluation
 Management
Objectives

 No drugs will cure skull base fractures.
 I do not own stock in medical equipment.
 However, I do drive a car, own a baseball bat and
work at the TDC hospital.
Disclosure for CME

 In US, 2 million head injuries occur yearly.
 Leading cause of death and disability of children.
 Motor vehicle accidents are leading cause of head
trauma in industrialized countries.
 Up to 1/3 of motor vehicle injuries involve head and
neck injuries and 28% of all fractures of involving MVA
are of the head and neck region.
Incidence
cElhaney JH, Hopper RH Jr, Nightingale RW, Myers BS. Mechanisms of basilar skull fracture. J Neurotrauma. 1995 Aug;12(4):669-78. PubMed PMID: 8683618.

 Skull base fractures occur in 3.5-24 % of head injuries.
 Traumatic Coma Data Bank states 25% of severe head
injuries
Incidence
Eisenberg, Howard M., et al. "Initial CT findings in 753 patients with severe head injury: a report from the NIH Traumatic Coma Data Bank.”
Journal of neurosurgery 73.5 (1990): 688-698.
http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-
francisco/
They account for
2% of all traumas

 Behbahani 2013- Retrospective study 1606 pt. in
Tuscon.
Incidence

 Skull base fracture incidence is increased with orbital
wall/rim fractures (36%) and ZMC Fractures (29.9%).
 Infrequent with nasal bone (7.7%) and mandible fractures
(4.0%).
 The incidence of skull base fracture was directly associated
with the number of facial fractures per patient; one facial
fracture (21.0%), two facial fractures (30.4%), and three or
more facial fractures (33.3%).
 Temporal bone fractures are associated 18-40% of the time.
 Frontal sinus fractures occur 15-20% of the time.
Incidence with other fracture(s)
Slupchynskyj, O. S., Berkower, A. S., Byrne, D. W. and Cayten, C. G. (1992), Association of skull base and facial fractures. The Laryngoscope, 102: 1247–1250
Temporal bone fracture: evaluation and management in the modern era. Johnson F - Otolaryngol Clin North Am - 01-JUN-2008; 41(3): 597-618
Gerbino G, Roccia F, Benech A, Caldarelli C. Analysis of 158 frontal sinus fractures: current surgical management and complications. J Craniomaxillofac Surg.
2000;28:133–139.

Anatomy
Examination of the skull and brain: method of removing the brain after it is severed from the body
Henry W. Cattell, 1903

Anatomy
https://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMDA08zTzdvvxBjI
wN_I_2CbEdFADiM_QM!/?segment=Cranium&bone=CMF&classification=93-Skull%20base%2C%20Skull%20base%20fractures&teaserTitle=
&showPage=diagnosis&contentUrl=/srg/93/01-Diagnosis/skull_base-skull_base.jsp

Anatomy
Base of skull: above,” ©2012 Icon Learning Systems, Plate # [11]. Netter Images. Used under NEOMED License. Accessed on [12-11-2013].

Anatomy: Fractures
RK Jackler Atlas of Skull Base Surgery and Neurotology 2009

 This includes posterior frontal sinus, roof of ethmoid,
cribriform and orbital roof.
 Classification (Damianos):
 Type 1- Cribriform fractures- linear through cribriform.
 Type 2- Frontoethmoid fracture- Ethmoids and medial
frontal sinus walls.
 Type 3- Lateral frontal fracture- Through the lateral
frontal sinus to the superomedial wall of orbit.
 Type 4- Mixed- any combination of above.
Anatomy: Anterior Skull Base
Fractures
Damianos SA, David BJ, Ameen AA, et al. Compound anterior cranial base fractures: classification using computerized tomography
scanning as a basis for selection of patients for dural repair. J Neurosurg 1998;88:471-477

Fractures
Type I Fractures

Fractures
Type II fractures

Fractures
Type III fractures

Anatomy: Middle Skull Base:
Temporal Bone

Temporal Bone
Collins JM, Krishnamoorthy AK, Kubal WS, Johnson MH, Poon CS. Multidetector CT
of temporal bone fractures. Semin Ultrasound CT MR. 2012 Oct;33(5):418-31

 2011-Kang-Seoul 128 patients 2003-2010.
 Hearing loss noted 78 pt.
 9 otic violating- with 8 (88.9%) having SNHL.
 68 otic sparing- with 18 (26.1%) having SNHL.
Temporal Bone
Kang HM, Kim MG, Boo SH, Kim KH, Yeo EK, Lee SK, Yeo SG. Comparison of the
clinical relevance of traditional and new classification systems of temporal bone
fractures. Eur Arch Otorhinolaryngol. 2012 Aug;269(8):1893-9

 Little and Kesser 2006- Showed 5 fold increase in facial nerve
injury, 25 fold increase in SNHL and 8 fold increase in CSF leaks
with otic capsule violating fractures.
 They also showed a correlation among OCV fracture and facial
nerve paresis or paralysis, In a large series of 820 temporal bone
fractures facial nerve paralysis occurred in 48% of OCV fractures
versus only 6% in OCS fractures.
 The incidence of otic capsule violating fracture is 2.5% to 5.6%.
Temporal Bone

 Uncommon, 9/25000 (0.39%) recorded in one case
series over 5 years.
 All patients had cranial nerve defects (II, III, IV, V, VI,
VII, VII), with VI and VII most common (66%).
 Longitudinal fractures have worse prognosis, with 3
out of 5 patients died from verebrobasilar injury.
 Transverse had 1 out of 4 die from carotid artery
injury.
Posterior Fossa: Clivus fractures
Clivus fractures: clinical presentations and courses Neurosurg Rev (2004) 27:194–198
DOI 10.1007/s10143-004-0320-

Posterior Fossa: Clivus fractures
Clivus fractures: clinical presentations and courses Neurosurg Rev (2004) 27:194–198
DOI 10.1007/s10143-004-0320-2

 High energy blunt trauma with compression,
rotational or lateral bending injuries to head.
 Type I- Axial compression with comminution of
occipital condyle-stable injury with no displacement.
 Type II- Direct blow that occurs with skull base and
occipital condyle- intact alar ligaments.
 Type III- Avulsion with lateral or rotational forces with
torn alar ligaments and fractures.
Posterior Fossa: Occipital
condylar fracture

Posterior Fossa: Occipital
condylar fracture

Evaluation
http://www.missmassacre.net/?p=2460

 Periorbital ecchymosis (raccoon eyes)
 Conjunctival hemorrhage
 Anosmia
 Mastoid ecchymosis (Battles sign)
 Vision changes
 CSF rhinorrhea or otorrhea
 Step off of supraorbital ridge
 Hearing loss
 Facial paralysis
 Facial numbness
Physical Exam

 Frontal bone fractures had the most clinical signs.
 Battle’s sign (100%) and unilateral Periorbital
ecchymosis (90%), bloody otorrhea (70%) are highest
predictive value for skull base fracture.
 Patients with GCS of 13-15, PPV for intracranial lesions
was (78%) periorbital ecchymosis, (66%) Battle’s sign
and (41%) bloody otorrhea.
Clinical signs
Positive predictive values of selected clinical signs associated with skull base fractures. (PMID:11105835)
Pretto Flores L, De Almeida CS, Casulari LA
Journal of Neurosurgical Sciences [2000, 44(2):77-82; discussion 82-3]

Periorbital Ecchymosis
http://rlbatesmd.blogspot.com/2010/07/blepharoplasty-complications-article.html

 Battle sign - Think Basilar Skull Fracture
Battle sign
http://www.dooey.net/OMFS/

CSF Rhinorrhea
http://amandela.sg/a-runny-nose-may-not-just-be-a-runny-nose/

 Eighty percent of cerebrospinal fluid (CSF) leaks occur
following nonsurgical trauma (16% surgical).
 Occur in 2% of all head traumas, and 12% to 30% of all
basilar skull fractures, M>F.
 50% appear in first 2 days, 70% in one week, and
almost all seen in 3 months.
CSF Rhinorrhea

CSF Rhinorrhea
REtRoSPECtivE StuDY oF SKuLL BASE FRACtuRE: A StuDY oF iNCiDENtS, ComPLiCAtioNS, mANAgEmENt, AND
outComE ovERviEW FRom tRAumA-oNE-LEvEL iNStitutE ovER FivE YEARS – Michael lemole, Md, Mandana Behbahani,
Ba (presenter), university of arizona college of Medicine

Cranial nerve injuries
http://kevinpremed.files.wordpress.com/2009/02/cranial-nerves.jpg

 CN I- anosmia- from anterior fossa injuries
(cribriform). Sense of smell may return over several
months. Workup is limited with CT scan.
 CN II- Blindness worst outcome- from damage to
the optic canal or orbit. Sphenoid body with sella
turcica damage can cause injury to the optic
chiasm, causing bitemporal blindness.
Cranial nerve injuries: Anterior
Cranial Fossa
Gjerris F. Traumatic lesions of the visual pathways. In: Vinken PJ, Bruyn GW, eds. Handbook of Neurology. Vol 24. New York:
Elsevier; 1976:27–57.
Kline LB, Morawetz RB, Swaid SN. Indirect injury of the optic nerve. Neurosurgery. 1984;14:756–764.

 CN III- Diplopia, impaired EOM.
 Noted dilated pupil, inability to move eye medially,
superiorly, or inferiorly (down and out). Usually
from direct frontal blow, which stretches the nerve
at the posterior cavernous sinus as it enters the
brain.
 Treatment consists of wearing a patch over the
affected eye, as spontaneous recovery usually
occurs in 4-6 weeks.
Cranial nerve injuries: Middle
Cranial Fossa
Elsevier; 1976:27–57.

 CN IV- diplopia-
 Least common injury site. Cause from stretching of
nerve as it exits from the dorsal midbrain.
 Treatment same as CN III, with patch and
spontaneous recovery.
 CN V- Sensory deficits to the face. V1-supraorbital, V2-
maxillary, V3-mandibular.
 V1 most commonly damaged portion, with injury at
supraorbital notch.
Cranial Fossa

 CN VI- diplopia. Damage to the clivus. Also stretched
or avulsed when leaving the pons. Unable to abduct.
Conservative treatment with spontaneous recovery.
 Superior orbital fissure fractures can damage CN III, IV,
VI and V1- known as superior orbital fissure syndrome.
When accompanied by blindness, it is known as orbital
apex syndrome and involves optic foramen.
Cranial Fossa
Elsevier; 1976:27–57.

 CN VII- facial paralysis. Most common temporal bone,
50% of transverse and 25% of longitudinal fractures as
injuries. ENoG of 90% denervation should undergo
surgery.
 CN VIII- Hearing loss, vestibular damage. Cochlear
and vestibular nerve damage, or damage to otic
capsule can lead to total degeneration with deafness
and labyrinthine dysfunction. Workup with
Audiogram, ABR, and ENG. Cochlear implants have
84% success rate of return to speech understanding.
Cranial Fossa
Elsevier; 1976:27–57.

 CN IX, X, XI- exit out of jugular foramen and CN XII exit out
of hypoglossal foramen.
 Glossopharyngeal injury leads to dysphagia and loss of gag
 Vagus nerve results in ipsilateral cord or palate weakness
with hoarseness.
 Spinal accessory nerve causes weakness with head
rotation and shoulder elevation. Hypoglossal nerve injury
causes atrophy of ipsilateral tongue.
 Treatment is usually supportive with therapy.
Cranial nerve injuries: Posterior
Cranial Fossa
Elsevier; 1976:27–57.

 New Orleans criteria
 CT required for minor head trauma (Loss of
consciousness with normal neurologic exam) if the
following apply:
 Headache, vomit, >60 yo, Drug/alcohol, seizure witness,
anterograde amnesia, soft tissue injury
Evaluation: Imaging
Smits M, Dippel DW, de Haan GG, Dekker HM, Vos PE, Kool DR, Nederkoorn PJ, Hofman PA, Twijnstra A, Tanghe HL, Hunink MG.
External validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head injury.
JAMA. 2005 Sep 28;294(12):1519-25. PubMed PMID: 16189365.

 X-Ray skull: Not recommended; delays diagnosis of
intracranial injury.
 It is not recommended for most head traumas. It has
some benefit for non accidental trauma in children.
Evaluation: Imaging
hornbury JR, Masters SJ, Campbell JA. Imaging recommendations for head trauma: a new comprehensive strategy. AJR Am J Roentgenol. Oct 1987;149(4):781-3

 HRCT scan is the gold standard for skull base injury. It
has the best modality to evaluate bony fractures.
 The slices should be 1-1.5 mm thick at the most.
 Helical CT scans are useful in the evaluation of
occipital condylar fractures.
 CT Angiography is an excellent, quick, non-invasive
technique for the assessment of cerebral vasculature.
Evaluation: Imaging: CT

Evaluation: Imaging: CT
http://www.jaypeejournals.com/eJournals/ShowText.aspx?ID=3093&Type=FREE&TYP=TOP&IN=_eJournals/images/JPLOGO.gif&IID=238&isPDF=NO

Imaging: CT
 Textbook of Head Injury Raj Kumar, A. K. Mahapatra JP Medical Ltd, 2012 - Medical - 320 pages

Imaging: CT
Multidetector CT of Temporal Bone Fractures John M. Collins, Aswin K. Krishnamoorthy, Wayne S. Kubal, Michele H. Johnson
, Colin S. Poon Seminars in ultrasound, CT, and MR 1 October 2012 (volume 33 issue 5 Pages 418-431

Approximately 50% of patients with skull base fractures
present with delayed ischemic brain damage. Carotid
injuries include carotid disruption, compression by
fracture fragments or associated hematoma, arterial
wall contusion or hematoma, arterial dissection, carotid
cavernous fistula, and occlusion.
Behbahani 2013- Retrospective study 1606 pt. in Tuscan,
16 patients had fractures extending to carotid canal, but
no carotid injures noted on angiographic studies.
Evaluation: Vascular injuries
Samii M, Tatagiba M. Skull base trauma: diagnosis and management. Neurol Res 2002;24:147-156

 Biffl et all (1999)
 A total of 249 patients underwent arteriography; 85
(34%) had injuries.
 Independent predictors of carotid arterial injury were:
Glasgow coma score ≤6, petrous bone fracture,
diffuse axonal brain injury, and LeFort II or III fracture.
Having one of these factors in the setting of a high-
risk mechanism was associated with 41% risk of injury.
Biffl WL, Moore EE, Offner PJ, Brega KE, Franciose RJ, Elliott JP, Burch JM.
Optimizing screening for blunt cerebrovascular injuries. Am J Surg. 1999

Sliker CW. Blunt cerebrovascular injuries: imaging with multidetector CT angiography. RadioGraphics
2008;28(6):1689–1708; discussion 1709–1710

 Provides greater soft tissue detail but less bony detail
compared to CT.
 FSE T-1 or T-2 with post contrast enhancement are
preferred methods to evaluate skull base.
 T-2 fat suppression with image reversal is used to
highlight CSF.
 T2 weighted thin sliced images (FIESTA) is used to
evaluate cranial nerves.
Imaging: MRI
Skull Base, Orbits, Temporal Bone, and Cranial Nerves: Anatomy on MR
Imaging Magn Reson Imaging Clin N Am 19 (2011) 439–456doi:10.1016/j.mric.2011.05.006

 CSF evaluation
 Halo or Ring Sign
 Bloody CSF placed on a piece of filter paper
 Blood will separate out from the CSF (central blood
with clear ring).
 The ring sign is not specific to bloody CSF
 Blood mixed with water, saline, and other mucus will
also produce a ring sign.
Evaluation: CSF
Rhinorrhea/Otorrhea
Dula, DJ, MD and Fales, F, MD. The 'Ring Sign': Is It a Reliable Indicator for Cerebral Spinal Fluid? Annals of Emergency Medicine, 1993;22:718-720

Evaluation: CSF
Rhinorrhea/Otorrhea

 Beta-2-transferrin
 Protein produced by enzymes only in CNS.
 Test requires 0.5cc of fluid.
 Highly sensitive and specific for CSF.
Beta-trace protein
 Found in CSF, heart, and serum.
 Not routinely ordered as it may be altered in many cases.
○ Elevated with renal insufficiency, multiple sclerosis,
cerebral infarctions, and some CNS tumors.
Evaluation: CSF
Rhinorrhea/Otorrhea
Moyer, P. Beta-Trace Protein Shows Promise as a Marker for Diagnosing CSF Leaks. Doctor’s Guide. Online[Available]:
http://www.docguide.com/dg.nsf/PrintPrint/5DF097A1EB04B3FA85256C3E00731E65, 2002

 Useful in detection of CSF leaks.
 Involve intrathecal administration of radiopaque
contrast (metrizamide, iohexol, or iopamido)
followed by CT scan.
 Up to 80% sensitivity.
 However results vary with intermittent leaks, and
contrast may obscure visualization of leak site.
Imaging: CT cisternograms
Meco C, Oberascher G, Arrer E, et al. Beta-trace protein test: new guidelines for the reliable diagnosis of
cerebrospinal fluid fistula. Otolaryngol Head Neck Surg 2003;129:508–17

CSF Rhinorrhea
http://www.chatrath.com/featuredcases.html

 Treatment begins with conservative management of
strict bed rest, HOB >30 degrees, no cough, sneezing,
straining.
 Currently, after two separate meta-analysis showed
conflicting data, a Cochrane review was done for
evaluation of prophylactic antibiotics for CSF leaks.
 The analysis concluded that the evidence does not
support the use of prophylactic antibiotics to reduce
the risk of meningitis in patients with basilar skull
fractures or basilar skull fractures with active CSF
leak.
CSF Rhinorrhea
Ratilal BO, Costa J, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilar
skull fractures. Cochrane Database Syst Rev 2006;(1): CD004884.

 Conservative management for 7 days has resolutions
rate of 85%.
 Continued leakage is then treated with lumbar
drainage of 10 ml/hr. This increases resolution rate to
90%.
 Therefore, surgical intervention is reserved for
patients who do not resolve with the above
measures.
CSF Rhinorrhea
Bell RB, Dierks EJ, Homer L, et al. Management of cerebrospinal fluid leak associated
with craniomaxillofacial trauma. J Oral Maxillofac Surg 2004;62(6):676–84.

 Skull base injuries offer complex fractures that
require thorough evaluations.
 Division in 3 cranial vaults provides a reasonable way
for evaluation.
 Radiographic evaluation is important, along with
history and physical exam.
 Treatment measure typically begin with conservative
treatment, with surgical intervention saved for severe
or persistent disease.
Conclusion

 Slupchynskyj, O. S., Berkower, A. S., Byrne, D. W. and Cayten, C. G. (1992), Association of skull base and facial fractures.
The Laryngoscope, 102: 1247–1250
 Eisenberg, Howard M., et al. "Initial CT findings in 753 patients with severe head injury: a report from the NIH
Traumatic Coma Data Bank." Journal of neurosurgery 73.5 (1990): 688-698.
 http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-san-francisco/
 Positive predictive values of selected clinical signs associated with skull base fractures. (PMID:11105835)
 Pretto Flores L, De Almeida CS, Casulari LA
Journal of Neurosurgical Sciences [2000, 44(2):77-82; discussion 82-3]
 http://rlbatesmd.blogspot.com/2010/07/blepharoplasty-complications-article.html
 https://www2.aofoundation.org/wps/portal/!ut/p/c0/04_SB8K8xLLM9MSSzPy8xBz9CP0os3hng7BARydDRwN3QwMD
A08zTzdvvxBjIwN_I_2CbEdFADiM_QM!/?segment=Cranium&bone=CMF&classification=93-
Skull%20base%2C%20Skull%20base%20fractures&teaserTitle=&showPage=diagnosis&contentUrl=/srg/93/01-
Diagnosis/skull_base-skull_base.jsp
 Textbook of Head Injury Raj Kumar, A. K. Mahapatra JP Medical Ltd, 2012 - Medical - 320 pages
 Driscoll CL, Lane JI. Advances in skull base imaging. Otolaryngol Clin North Am. 2007 Jun;40(3)
 cElhaney JH, Hopper RH Jr, Nightingale RW, Myers BS. Mechanisms of basilar skull fracture. J Neurotrauma. 1995
Aug;12(4):669-78. PubMed PMID: 8683618.:439-54, vii. Review. PubMed PMID: 17544690.
 http://www.lhsc.on.ca/Health_Professionals/CCTC/edubriefs/baseskull.htm
 Gjerris F. Traumatic lesions of the visual pathways. In: Vinken PJ, Bruyn GW, eds. Handbook of Neurology. Vol 24. New
York: Elsevier; 1976:27–57.
 Base of skull: above,” ©2012 Icon Learning Systems, Plate # [11]. Netter Images. Used under NEOMED License.
Accessed on [12-11-2013].
 Kline LB, Morawetz RB, Swaid SN. Indirect injury of the optic nerve. Neurosurgery. 1984;14:756–764.
References

 Temporal bone fracture: evaluation and management in the modern era. Johnson F - Otolaryngol Clin North Am - 01-JUN-2008;
41(3): 597-618
 Gerbino G, Roccia F, Benech A, Caldarelli C. Analysis of 158 frontal sinus fractures: current surgical management and complications.
J Craniomaxillofac Surg. 2000;28:133–139.
 REtRoSPECtivE StuDY oF SKuLL BASE FRACtuRE: A StuDY oF iNCiDENtS, ComPLiCAtioNS, mANAgEmENt, AND outComE ovERviEW
FRom tRAumA-oNE-LEvEL iNStitutE ovER FivE YEARS – Michael lemole, Md, Mandana Behbahani, Ba (presenter), university of
arizona college of Medicine
 Little SC, Kesser BW. Radiographic classiﬁcation of temporal bone fractures: clinical predictability using a new system. Arch
Otolaryngol Head Neck Surg 2006;132(12):1300–4
 Sliker CW. Blunt cerebrovascular injuries: imaging with multidetector CT angiography. RadioGraphics
 2008;28(6):1689–1708; discussion 1709–1710
 Kang HM, Kim MG, Boo SH, Kim KH, Yeo EK, Lee SK, Yeo SG. Comparison of the clinical relevance of traditional and new
classification systems of temporal bone fractures. Eur Arch Otorhinolaryngol. 2012 Aug;269(8):1893-9
 Multidetector CT of Temporal Bone Fractures John M. Collins, Aswin K. Krishnamoorthy, Wayne S. Kubal, Michele H. Johnson,
Colin S. Poon Seminars in ultrasound, CT, and MR 1 October 2012 (volume 33 issue 5 Pages 418-431
 The analysis concluded that the evidence does not support the use of
 prophylactic antibiotics to reduce the risk of meningitis in patients with basilar skull
 fractures or basilar skull fractures with active CSF leak
 Bell RB, Dierks EJ, Homer L, et al. Management of cerebrospinal fluid leak associated
 with craniomaxillofacial trauma. J Oral Maxillofac Surg 2004;62(6):676–84.
References

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