Professional Documents
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Objectives
Incidence
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.
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.
Incidence
Skull base fractures occur in 3.5-24 % of head injuries. Traumatic Coma Data Bank states 25% of severe head injuries
They account for 2% of all traumas
http://www.nelsonbarry.com/car-accident/what-are-the-5-most-common-car-accident-injuries-in-sanfrancisco/ 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.
Incidence
Behbahani 2013- Retrospective study 1606 pt. in Tuscon.
Anatomy
Examination of the skull and brain: method of removing the brain after it is severed from the body Henry W. Cattell, 1903
Anatomy
Anatomy
Anatomy
Anatomy
Base of skull: above, 2012 Icon Learning Systems, Plate # [11]. Netter Images. Used under NEOMED License. Accessed on [12 -11-2013].
Anatomy
Anatomy
Base of skull: above, 2012 Icon Learning Systems, Plate # [11]. Netter Images. Used under NEOMED License. Accessed on [12 -11-2013].
Anatomy
Anatomy
Base of skull: above, 2012 Icon Learning Systems, Plate # [11]. Netter Images. Used under NEOMED License. Accessed on [12 -11-2013].
Anatomy: Fractures
Anatomy: Fractures
Anatomy: Fractures
Anatomy: 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
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
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
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
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
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
Clivus fractures: clinical presentations and courses Neurosurg Rev (2004) 27:194198 DOI 10.1007/s10143-004-0320-
Clivus fractures: clinical presentations and courses Neurosurg Rev (2004) 27:194198
DOI 10.1007/s10143-004-0320-
Evaluation
http://www.missmassacre.net/?p=2460
Physical Exam
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
Clinical signs
Frontal bone fractures had the most clinical signs. Battles 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%) Battles sign and (41%) bloody otorrhea.
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
Battle sign - Think Basilar Skull Fracture
http://www.dooey.net/OMFS/
CSF Rhinorrhea
http://amandela.sg/a-runny-nose-may-not-just-be-a-runny-nose/
CSF Rhinorrhea
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
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
http://kevinpremed.files.wordpress.com/2009/02/cranial-nerves.jpg
Gjerris F. Traumatic lesions of the visual pathways. In: Vinken PJ, Bruyn GW, eds. Handbook of Neurology. Vol 24. New York: Elsevier; 1976:2757. Kline LB, Morawetz RB, Swaid SN. Indirect injury of the optic nerve. Neurosurgery. 1984;14:756764.
Evaluation: Imaging
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
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.
Evaluation: Imaging
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.
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
Evaluation: Imaging: CT
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
http://www.jaypeejournals.com/eJournals/ShowText.aspx?ID=3093&Type=FREE&TYP=TOP&IN=_eJournals/images/JPLOGO.gif&IID=238&isPDF=NO
Imaging: CT
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
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
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
Samii M, Tatagiba M. Skull base trauma: diagnosis and management. Neurol Res 2002;24:147-156
Sliker CW. Blunt cerebrovascular injuries: imaging with multidetector CT angiography. RadioGraphics 2008;28(6):16891708; discussion 17091710
Imaging: MRI
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.
Skull Base, Orbits, Temporal Bone, and Cranial Nerves: Anatomy on MR Imaging Magn Reson Imaging Clin N Am 19 (2011) 439456doi:10.1016/j.mric.2011.05.006
Imaging: MRI
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
Moyer, P. Beta-Trace Protein Shows Promise as a Marker for Diagnosing CSF Leaks. Doctors Guide. Online[Available]: http://www.docguide.com/dg.nsf/PrintPrint/5DF097A1EB04B3FA85256C3E00731E65, 2002
Imaging: CT cisternograms
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.
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;129:50817
CSF Rhinorrhea
CSF Rhinorrhea
http://www.chatrath.com/featuredcases.html
CSF Rhinorrhea
CSF Rhinorrhea
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.
Ratilal BO, Costa J, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database Syst Rev 2006;(1): CD004884.
CSF Rhinorrhea
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.
Bell RB, Dierks EJ, Homer L, et al. Management of cerebrospinal fluid leak associated with craniomaxillofacial trauma. J Oral Maxillofac Surg 2004;62(6):67684.
Conclusion
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.
References
Slupchynskyj, O. S., Berkower, A. S., Byrne, D. W. and Cayten, C. G. (1992), Association of skull base and facial fractures. The Laryngoscope, 102: 12471250 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=93Skull%20base%2C%20Skull%20base%20fractures&teaserTitle=&showPage=diagnosis&contentUrl=/srg/93/01Diagnosis/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; 1976:2757. 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;14:756764.
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;28:133139. 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 classication of temporal bone fractures: clinical predictability using a new system. Arch Otolaryngol Head Neck Surg 2006;132(12):13004 Sliker CW. Blunt cerebrovascular injuries: imaging with multidetector CT angiography. RadioGraphics 2008;28(6):16891708; discussion 17091710 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):67684.