Fractures of the floor of the anterior cranial fossa. The selection of patients for dural repair

Abstract

1. A series of 87 patients operated on because of subfrontal fractures is reported. In 73 of these a fistulous lesion (connecting the brain with the nose or the accessory air sinuses) was displayed and was repaired. Almost always a bifrontal exploration has been made, because the lesions were bifrontal in 43 per cent of cases. The mean follow‐up period was 4 years; to date no instances of postoperative meningitis or rhinorrhoea have occurred. 2. Our experience suggests that cerebrospinal rhinorrhoea accompanying fractures of the facial bones (without fractures of the skull vault) can safely be treated conservatively. 3. Damaged brain adheres to the lips of the torn dura and permanently prevents natural healing, thereby creating a continuing threat to life. Consequently it is recommended that all frontal fractures lying below the hairline and all comminuted anterior temporal fractures should be referred for expert neurosurgical/neuroradiological assessment. This is because 42 per cent of the patients requiring operative repair were selected after tomographic studies of the anterior fossa; they had not presented with the classic criteria of cerebrospinal rhinorrhoea, intracranial air, or meningitis.

Compound anterior cranial base fractures: classification using computerized tomography scanning as a basis for selection of patients for dural repair

“…5,7 Our experience agrees with this finding and those of many other reports that have demonstrated that compound skull base fractures can indeed be complicated by meningitis, regardless of their association with a CSF leak. 2,5,9,[12][13][14][15]21,22,26,28…”

“…Instead, surgical decision making is primarily guided by whether the fracture is associated with persistent cerebrospinal fluid (CSF) rhinorrhea. 1,4,25 Rhinorrhea or tension pneumocele, however, can develop many (5-45) years after injury, 8,9,13,14,16,19,21,22 and a fatal attack of pneumococcal meningitis, without preced-ing CSF rhinorrhea, may be the first presentation of a posttraumatic fistula. 8 The reasons for poor healing in such cases are not fully understood.…”

Diagnosis and treatment of frontobasal skull fractures

“…While some advocate early surgical treatment [11,15], others prefer delayed surgery [14,16,18]. At this centre surgery is usually performed at the end of the second week after the trauma, when brain edema has mostly resolved.…”

Supraorbital Keyhole Surgery for Optic Nerve Decompression and Dura Repair

“…Post-traumatic CSF leakage is a common complication in head injury patients, since pneumo-cephalus and cerebral contusion of base of frontal lobes strongly suggest dural laceration (Jefferson et al, 1972;Ghoshhajra, 1980). Traditionally, CSF rhinorrhea has been treated conservatively, and surgical treatment remains a matter of controversy.…”

“…The modern keyhole craniotomy concept was proposed by Fukushima (Fukushima et al, 1991;Jefferson et al, 1972), who noted the possibility of reducing traumatic manipulation of all tissue encountered, with the concept that the skin incision, craniotomy, or dural opening need not approximate the size of a keyhole. We applied this concept to treat traumatic optic neuropathy and cerebrospinal fluid (CSF) leakage.…”