Predicting Outcome and Conservative Treatment Failure in Patients with Skull Fracture after Traumatic Brain Injury: A Retrospective Cohort Study

Abstract

Objective Traumatic brain injury (TBI) remains a major cause of morbidity and mortality worldwide. The prognostic value of skull fracture (SF) remains to be clearly defined. To evaluate the need for neurosurgical intervention and determine the risk factors of conservative treatment failure (CTF), we retrieved from the hospital database the records of patients with SF after TBI. Methods We analyzed 146 consecutive patients (mean age: 49.8 ± 17.5 years) treated at the department of neurosurgery in a 5-year period. Clinical data, radiologic reports, and laboratory results were evaluated retrospectively. Results A total of 63% of patients were treated conservatively, 21.9% were operated on immediately, and 15.1% experienced CTF. Overall, 73.3% had a favorable outcome; the mortality rate was 13%. Intracranial bleeding occurred in 96.6% of cases, basilar SF in 61%, and cerebrospinal fluid (CSF) leak in 2.8%. The independent risk factors for outcome were Glasgow Coma Scale (GCS) score, age, and platelet count (PCT). The independent risk factors for CTF were epidural hematoma, subdural hematoma, mass effect, edema, international normalized ratio, PCT, mean platelet volume, and CSF leakage. The consensus decision tree algorithm used at the accident and emergency department indicated patients with no need for neurosurgical intervention with an accuracy of 91.7%, sensitivity of 88.9%, and featured the importance of mass effect, GCS, and epidural hematoma. Conclusions Tests included in the complete blood count appeared useful for predicting the course in patients with SF, although the most important factors were age and neurologic status, as well as radiologic findings. Our decision tree requires further validation before it can be used in everyday practice.

Factors with the strongest prognostic value associated with in-hospital mortality rate among patients operated for acute subdural and epidural hematoma

“…The skull fracture among TBI patients is associated with an increased risk of neurosurgically-relevant intracranial lesion [64]. Bobeff et al showed a higher incidence of complications during treatment in patients with linear skull fracture [41]. Our results did not include fractures as factors of unfavorable prognosis.…”

“…High glucose is a cause of secondary insults for the patients after TBI, and it is associated with a poorer outcome [40]. This trend was also noted in observations carried out by Bobeff et al The authors showed that patients with glucose levels exceeding 160 mg/dL are at a higher risk of complications after treatment [41]. Similarly, the work of Corbett et al [42] showed that disorders in this area are associated with higher risk of unfavorable outcome at 18 months after severe TBI.…”

“…TBI-associated changes may also be seen in patients' blood counts. Bobeff et al [41] showed that abnormalities in hematological parameters such as hemoglobin (Hg), hematocrit (Ht), and red blood cell count (RBC) are an independent risk factor for unfavorable prognosis. Interestingly, the authors also emphasized the role of red blood cell distribution width (RDW) and platelet count disorders in predicting patient mortality.…”

Role of Conservative Treatment and Outcome of Traumatic CSF Rhinorrhea

“…Common entry points include the sphenoidal roof, lamina cribrosa, petrous bone, middle ear, and Eustachian tube, facilitating CSF's access into the nasal cavity. However, determining the leak's lateral origin based on the nostril side is often unreliable, with nasal cavity fractures due to traumatic CSF leaks comprising 3-4% of cases (4)(5)(6). Typically, acute traumatic CSF leaks first present with bloody cerebrospinal fluid, which eventually clears.…”