Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 23 (2021) 100906
Available online 15 September 2020
Research Article
A study of clinical presentation and management of base of skull fractures in our tertiary care centre
Bhaskar Naidu
*, Visweswaran Vivek, Krishnaswamy Visvanathan, Ravi Shekhar, Sudha Ram, Krishnamurthy Ganesh
Department of Neurosurgery, Sri Ramachandra Medical College (SRMC), SRIHER, No. 1, Ramachandra Nagar, Porur, Chennai 600 116, India
A R T I C L E I N F O Keywords:
Base of skull fracture Head trauma Cranial nerve injury CSF leak
A B S T R A C T
Basal skull fractures remain one of the more difficult head and neck fractures to evaluate and treat. They often have extensive associated injuries, both intracranial and extra-cranial, which make the management of the pa- tients more challenging.
The aim of this study was to analyze the clinical presentations, management and outcome of patients with base of skull fractures. This study was conducted in 174 cases with evidence of base of skull fractures on CT scans, which satisfied the inclusion and exclusion criteria. All patients were clinically evaluated and treatment as defined by the senior consultants in the department of neurosurgery. At the end of the study, clinical presen- tation, management and outcome of these patients were evaluated.
Base of skull fracture is common in head injuries, seen in 53% of cases in this study group and most common in the 3rd decade of life. Most common mode of injury was road traffic accidents in adults and fall in children.
Raccoon eye sign was seen only in 26.1% of cases. Temporal bone was the most common bone involved. Acute hemorrhagic contusion was the most commonly associated intracranial finding followed by acute Subdural hematoma. Acute subdural hemorrhage was the most common indication for surgery. Fifty eight percentage of patient recovered with a GCS of 13 or more. The mortality rate in this study group was 10.34%. However, the cause of death was the associated severe intracranial injury.
1. Introduction:
Trauma is a preventable epidemic neglected by many governments, especially in developing countries. Many of the devastating effects of trauma are often from head injury [1]. Fractures of skull base have been reported to occur in 3.5–24.0 percent of head injury patients [2].
Base of skull fracture is basically a linear fracture in the skull base.
These fractures are often a part of a convexity fracture that has extended into the skull base, though they can also occur alone. They occur chiefly due to either direct impact or because of propagation of stress waves through the skull as a result of remote impact. They also occur as a consequence of impact to facial bones [3]. The skull base is prone to fracture at certain anatomical sites like sphenoid sinus, foramen mag- num, petrous temporal ridge, inner portion of sphenoid wings at skull base. The middle cranial fossa is the weakest with thin bones and mul- tiple foramina which predisposes it to fractures [2,3]. The unique
anatomical relationship of the base of skull is responsible for other particular problems that may arise after injury. Because the duramater is adherent firmly to the skull base, it is likely to be lacerated by the fractured bone. Such a fracture places the subarachnoid space in direct contact with the sinuses, middle ear structures or mastoid cells providing a pathway for CSF leak, infection (meningitis, abscess) and/or persistent fistula [4–7]. Basal fractures often traverse foramina and thereby damage cranial nerves [6,8] and blood vessels [6,9]. The radiological imaging techniques are relied upon for inferring the nature of injury in all medico-legal injury either presence or absence of skull fracture, simple or grievous [10]. Modern CT scans with bone windows, thin section cuts of up to 1–1.5 mm and coronal cuts provide improved detection and resolution of even tiny fractures without increased exposure to radiation [11]. MRI is of supplementary value for suspected vascular injuries and when cranial nerve palsies occur in order to recognize neural compression [12].
* Corresponding author at: Sri Ramachandra University, Sri Ramachandra Medical College (SRMC), E27, Staff Quarters, No. 1, Ramachandra Nagar, Porur, Chennai 600 116, India.
E-mail addresses: [email protected] (B. Naidu), [email protected] (V. Vivek).
Contents lists available at ScienceDirect
Interdisciplinary Neurosurgery: Advanced Techniques and Case Management
journal homepage: www.elsevier.com/locate/inat
https://doi.org/10.1016/j.inat.2020.100906
Received 5 August 2020; Received in revised form 18 August 2020; Accepted 5 September 2020
Fig. 1. Treatment algorithm for Traumatic brain injury at our tertiary care centre.
Management of a patient entirely depends on the clinical status and neuro-radiological findings of the patient and associated injuries. Severe head injury requiring craniotomies should be given first priority as a lifesaving procedure. Delayed complications of base of skull fractures like CSF leak, can be dealt with once the patient has stabilized.
This study was an attempt to study the clinical presentations, man- agement and outcome of such patients so as to be thorough with man- agement of traumatic head injury patients with base of skull fractures in the future.
2. Materials and methods
This was a longitudinal observational study, conducted in the Department of Neurosurgery, Sri Ramachandra Medical College &
Research Centre (SRMC&RC). It was approved by the University ethical clearance committee.
Out of the 342 cases which presented to the department of neuro- surgery with history of head trauma, 174 cases with evidence of base of skull fractures on CT scans, willing for admission and management were included in the study between September 2015 and February 2016.
Fig. 1 describes our treatment protocol for patients with traumatic brain injury.
At Admission: Once the patients were brought to the Emergency department with the history of head trauma, patients underwent triage and received primary aid and resuscitation. After the primary survey, cervical spine was stabilized with collar and patients with compromised airway and breathing or low GCS (8 or less) were intubated and venti- lated. Further hemodynamic instability was treated accordingly. Pa- tients suspected to be at high risk for post traumatic seizures were loaded with intravenous fosphenytoin as per body weight. Tetanus toxoid was given to all patients regardless of mode of injury. Once the patient was stabilized CT scan of the head and other parts of the body as required were performed and neurosurgical consult was sought.
Neurosurgical evaluation: A detailed history of events regarding time of the injury, mode of the injury, use of helmet, past medical history, alcohol intoxication, and presenting symptoms like loss of conscious- ness, amnesia, nausea, vomiting, headache, seizures or any ENT bleed were noted. In case of an unconscious patient history was obtained from the patients accompany. A careful and detailed neurological examina- tion was performed for each patient regarding level of consciousness, arrival GCS and follow up GCS, pupillary status and cranial nerve function, motor and sensory involvement when possible, and signs specific for base of skull fractures including active CSF leak, Raccoons eye sign and Battle’s sign. Patients were categorized into three cate- gories according to their GCS score – mild (GCS 13–15), moderate (GCS 9–12) and severe head injury (GCS <=8). CT scan of the head was performed using a 64 slice high resolution CT scan machine. Details of the fracture of the base of skull were noted including the bones involved and the extension into anterior, middle or posterior cranial fossa.
Associated intracranial findings including acute intracranial hema- tomas, pneumocephalus and skull vault fractures were also noted.
Course in the hospital: A detailed neurological examination of all the patients was done every-day and their improvement/deterioration was documented. Repeats CT scans were performed at appropriate intervals to check the status of intracranial injuries and progression/regression of the disease process.
Follow up: All the patients with base of skull fractures were reviewed in the outpatient department at 2 weeks, 1 month and 3 months after discharge. Neurological status, and improvement or deterioration in neurological deficits, if any, was noted. Follow up CT scans were per- formed as required and findings documented.
3. Results
3.1. Analysis of demographic valuables
The total number of patients enrolled in the study was 174. In this study, there was a preponderance of patients aged between 21 and 30 years (56 cases) who had base of skull fracture following head trauma, constituting about 32% of the study population. Another 25.8% (45 cases) of the study population were aged between 31 and 40 years.
Below Bar graph 1 shows the age distribution of the cohort. There was a preponderance of the male patients when compared to female patients.
Males were to 83.9% (146 cases) of the study population and the male to female ratio was 5.2:1. Road traffic accidents were the most common mode of injury in 79.3% (138 cases) of patients followed by fall from a height that constituted 9.7% (17 cases) of patients as mode of injury.
3.2. Analysis of patients based on symptomatology
Loss of consciousness was the most common symptom present in 72.4% (126 cases) of patients followed by local pain/wound; vomiting and headache in 65.5%, 48.2% and 27.58% of patients respectively.
However 18.9% (33 cases) of patients did not have any symptoms at the time of presentation.
In this study 39% of patients (68 cases) had severe head injury with GCS of 8 or less, 32.1% and 28.7% had mild (56 cases) and moderate (50 cases) head injury respectively. Local injury to the scalp and face was the most common examination finding in 58.6% of the patients followed by Racoon eye sign and cranial nerve injury in 26.4% and 20.6%
respectively.
3.3. Analysis of patients based on imaging findings
Temporal bone was most commonly fractured bone in 47.1% of patients (82 cases) followed by occipital bone constituting 44.8% (78 cases) of study population. Frontal and sphenoid bone fracture were seen in 35.6% and 37.3% of patients in this study group. Middle cranial fossa base was the most commonly fractures area seen in 58.6% of the patients (102 cases) followed by posterior and anterior cranial base, constituting 49.4% and 36.7% of the patients in the study group. Table 1 summarizes the location of basal skull fracture.
Temporal bone fractures were categorized according to the part of Bar Graph 1.Shows the age distribution of the cohort.
Table 1
Distribution of location of basal skull fracture.
Cranial fossa Number of cases Percentage %
Anterior 64 36.78
Middle 102 58.62
Posterior 86 49.42
part, seen in 74.3% of the cases that had temporal bone fracture.
Squamous and petrous temporal fractures were seen in 63.4 and 58.5%
of the patients in this study group.
Contusions were the most commonly associated intracranial findings seen in 50% of patients. Acute SDH, Acute EDH and pneumocephalus was seen in 35.6%, 28.1% and 21.2% of patients. However, 13.7% of patients (24 cases) had no associated intracranial findings despite hav- ing a base of skull fracture.
3.4. Analysis of associated cranial nerve injuries, CSF leak
Olfactory nerve injury was the most common, found in 12.06% (21 out of 174) cases followed by facial nerve in 6.32% (11 out of 174) cases.
Out of 174, 57 patients (32.75%) did not have any signs of cranial nerve injury. However 81 out of 174 cases (46.5%) could not be assessed for cranial nerve deficits either due to low GCS or severe facial injuries.
Table 2 summarizes the distribution of patients with associated cranial nerve injury. 10.34% of patients (18 out of 174) had CSF leaks. Amongst these cases CSF rhinorrhea was more common found in 66.67% (12) of these cases.
Out of the 174 cases of base of skull fracture, 73.56% (128 out of 174) of patients were treated conservatively. Only 26.44% (46 cases) were treated surgically for various indications. Table 3 describes the indications for surgery. Among these cases acute subdrual hematoma was the most common indication found in 34.78% of surgically treated cases, followed by contusions which constituted 28.26% of the surgi- cally treated patients. In this study group, associated facial injuries were found in 69 cases which constituted 39.65% of the study population. In these cases zygoma fractures were the most common, constituting to 52.17% of facial injuries followed by orbital wall fractures in 46.37% of all facial injuries.
Most commonly performed procedure was decompressive hemi- craniectomy, acute subdural hematoma being the commonest indication for surgery. Table 3 summarizes the surgical interventions.
3.5. Analysis of patients based on outcome
In this study group, at the time of follow up, 58.6% (102 out of 174) of the patient had good recovery with a GCS of 13 or more. Total deaths in this study group including patients who were declared brain dead were 10.34% (18 cases).
4. Discussion
The description of skull fracture including the base of skull has been
described in literature as early as the 11th century [13]. Traumatic brain injury remains a major public health issue worldwide, especially in developing countries like India with 100,000 lives lost every year due to traumatic brain injury [14]. This signifies the importance of public health education and creating awareness among the population. Inci- dence of base of skull fracture in head injuries has been reported to be 3.5–24.0% [2,3]. Most of these were associated with major intracranial injuries requiring surgical treatment. Hence there is a need for quicker and accurate diagnosis of head injuries with base of skull fractures so that appropriate and emergency management of such patients can be done and survival can be improved.
The incidence of base of skull fractures in the present study was 53%
(174 out of 328 cases). In contrast, the traumatic coma data bank in a prospective series of severe head injury reported that 25% had basilar skull fractures [15]. However, Tandle et al. found the incidence of base of skull fracture in their study to be 35%. Similarly, Wani et al. in their study found the incidence to be 24% [2]. This study had similar features of another study, Rupani et al. who found incidence of base of skull to be 40% [16]. There have been various studies reporting different in- cidences of base of skull fractures. However this percentage should be considered to be under-reported as many of the patients who suffer head injury, especially in India, do not reach adequate treatment and diag- nostic facilities in time.
The present study found that base of skull fracture was more com- mon in the 3rd decade of life constituting to 32% of all the cases. Rupani et al. found the incidence of base of skull fracture to be higher in 5th decade of life [16]. Given that most of the cases included in this study group were younger adolescents and young adults who had accidents while traveling in a two wheeler without using a helmet; the incidence was thus higher in this age group.
The Indian head injury foundation reveals that road traffic accidents are the leading cause of head trauma in India in 60% of the cases. Rupani et al. reported vehicular accidents to be the cause of head injury with base of skull fracture in 70% of the cases [16]. Thangaraj et al. reported fall from height and road traffic accidents as the etiological factors in 36% and 32% respectively [15]. In the present study road traffic acci- dents were the cause of head injury and base of skull fractures in 79% of the cases. Hence this points to the fact that there is an utmost necessity to focus on education of the general population regarding safety pre- cautions during travel.
In the present study loss of consciousness was the most common presenting complaint in 72% of the study population followed by pain, swelling or wound at the site of injury (65.5%) and vomiting (48.27%) and headache (27.58%). Post traumatic amnesia was seen in 24.1% of patients and only 8% of patients presented with history of seizures.
However 19% of patient had no symptoms at the time of presentation.
When classified according to the GCS, 39% of patients had severe head injury. Mild and moderate head injury was seen in 32% and 28% of patients respectively. Patel et al. in their study found their study popu- lation to have mild, moderate and severe head injury in 50%, 26% and 24% cases [17]. In this study group, RES was seen in only 26% of pa- tients. Kral et al. identified RES in 14 of 67 patients (21%) with frontal fractures, while Goh et al. reported RES in 52% of patients with skull base fractures [18,19]. Thus RES is a useful clinical feature suggestive of base of skull fracture. However its absence does not rule out a basilar skull fracture.
Basal fractures often traverse foramina and thereby damage cranial nerves and blood vessels [6,8,9]. Cranial nerve injury was seen in 21% of the cases. Patel et al. found cranial nerve involvement in 67% of their study group [17]. In their study, facial nerve injury was seen in 4.32% of cases. Whereas, incidence of facial nerve injury was 6.32% in this study.
Olfactory nerve was injured in 12.06% of cases making it the most commonly injured cranial nerve in this study group. However, the lower incidence of cranial nerve injury could be justified by the fact that many patients who were suspected to have cranial nerve injury could not undergo appropriate examination for confirmation of cranial nerve Table 2
Distribution of sample according to cranial nerve injury.
Cranial nerve Number of cases Percentage %
CN I 21 12.06
CN II 8 4.59
CN III, IV, VI 6 3.44
CN VII 11 6.32
CN IX, X, XI 2 1.14
Table 3
Distribution of sample according to surgical procedure.
Indication for surgery Number of
cases Percentage
%
Craniotomy and evacuation of hematoma 12 26.08
Decompressive hemicraniectomy 23 50.00
Craniotomy with contusion excision/lobectomy 7 15.21 ACF Base repair (Bilateral frontal craniotomy/
endoscopic repair) 4 8.69
Total 46 100
involvement due to their low GCS or extensive facial injuries during the course of the hospital.
Temporal bone was the most commonly fractured bone among all the cases of base of skull base fracture constituting to 47% of the cases.
Rupani et al. and Wani et al. found temporal bone fractures in 40.3% and 47% of cases in their study groups, respectively [2,16]. The results of fractures of base of skull according to different bones as studied by Rupani et al. have been compared with the present study in the Table 4 [16].
The most commonly involved area of fracture was middle cranial base in 58% of the cases in this study group. Wani et al. however found anterior cranial base to be more often involved (51%) in their study group [2]. Associated CSF leak with base of skull fractures has been described to occur in 10–30% of cases in contrast to a study which described incidence of CSF leak to be 43% in their group. In the present study group, CSF leak was found in 10.34% of patients.
Majority of the patients were treated conservatively (74%). However 26% of patients required surgical mode of treatment for various asso- ciated intracranial findings. Base of skull fracture itself was not a pri- mary indication for emergency surgery. The most common indication for surgery was acute subdural hemorrhage followed by contusions.
As much as 39.6% of subjects had associated facial injuries amongst which zygoma fractures were the most common constituting to 52% of cases followed by orbital wall fracture seen in 46.3% of cases. Most of these subjects required surgical treatment. In this study group, at the time of follow up, 58.6% of the patient had good recovery with a GCS of 13 or more. Finally total deaths including patients who were declared brain dead were 10.34%.
5. Conclusion
The incidence of base of skull fracture in the present study was more than half of the case population. Noteworthy is the point that most of the cases included in this study group were younger adolescents and young adults who had accidents while traveling in a two wheeler without using a helmet. They account for the most productive age group in the coun- try. Hence, there is an utmost necessity to focus on education, dissem- ination of relevant statistics to the general population starting from schools to work places to homes through various communication media regarding safety precautions during travel in order to prevent the mor- tality and morbidity from such traumatic brain injury.
6. Source(s) of support None.
7. Presentation at a meeting None.
Conflict of Interest None.
Acknowledgement None.
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Table 4
Comparison of fractured bones between the present study and study conducted by Rupani [16] et al.
Bones involved Present study Rupani [16] et al.
Frontal 35.6% 56.2%
Sphenoid 37.3% 14.1%
Temporal 47.1% 40.3%
Occipital 44.8% 36.4%