7.2  Management of Skull Base and Dural Injury

7.2  Management of Skull Base

and Dural Injury

(Loew et al. 1984; O Brian and Reade 1984; Buchanan et al. 2004)

Traumatic CSF leakage occurs with skull base fractures adjacent to the pneumatized paranasal sinuses, the temporal bone and the mastoid, where the dura and presumably the arachnoid rupture.

Cerebral injury directly following impact and infection following bacterial migration from the pneumatized­ spaces may occur (Jamieson and Yelland 1973; Flanagan et al. 1980; Hubbard et al. 1985; Georgiade et al. 1987; Schmideck and Sweet 1988).

CSF leakage ceases without intervention within 24 h in 35% of cases, within 48 h in 68% and in 85% within a week (Mincy 1966; Schmideck and Sweet 1988). This has a major impact upon whether or not CSF leakage requires surgical repair.

Average ebbing time in manifested liquorrhea in frontobasal fractures without intervention

Controversy exists concerning the exact timing for the surgical repair of frontobasal dural defects (Dagi and George 1988; Schaller 2002).

The following scenarios are managed in different ways:

7.2.2  Skullbase Fractures with CSF Leak without Severe TBI

Isolated injuries including dural rupture are usually repaired late (Probst and Tomaschett 1990).

7.2.3  Skullbase Fractures with CSF Leak with Severe TBI

In the acute phase after severe TBI, brain edema, elevated ICP and the presence of cerebral contusions, the brain is vulnerable to further injury by surgical manipulation. Therefore, repair of a persistent CSF leak is usually recommended 1–2 weeks after the injury (Loew et al. 1984; Sprick 1988). Surgery should be delayed in the case of persistant impaired consciousness, particularly with DI or hyperthermia.

7.2.1  Skullbase Fractures with CSF Leakage

Persistent rhinorrhea in the context of a frontal skullbase fracture requires surgical intervention (Fonseca and Walker 1991; Godbersen and Kügelgen 1998a, b).

Conservative management, particularly of multifragmented frontobasal fractures, is associated with a significant risk of meningitis (Loew et al. 1984).

Surgery decreases this risk. The rate of postoperative meningitis has been reported as low as 3.8% (McGee et al. 1970; Spetzler and Zabramski 1986; Sakas et al. 1998; Kästner et al. 1998). For this reason, early surgery is attempted in frontobasal fractures with rhinorrhea with and without CT evidence of intradural air. This principle is similarly applied if rhinorrhea and infection occur at a later stage after injury (Probst 1971; Russel and Cummings 1984; Probst 1986).

7.2.4  Combined FrontobasalMaxillofacial Fractures with CSF Leakage with or without Severe TBI

In the context of a possible severe TBI, with increased complexity of the injury, the repair of a frontobasal CSF leak combined with that of maxillofacial fractures should be carried out as early as possible (Joss et al. 2001; Joseph et al. 2004).

7.2.4.1  Skullbase Fractures with Spontaneously Ceased CSF Leakage

If CSF leakage stops spontaneously, this may or may not indicate sufficient healing of the rupture. More so, the brain appears to seal off CSF flow temporarily. There