Skull base fracture from penetrating trauma by a metal straw: A case report

•. Brain and cervical spine imaging is often appropriate in patients with suspected high-energy facial or skull base fractures. •. A systematic approach to plain radiograph analysis is required to screen patients for significant midfacial fractures and CT is not required for uncomplicated fractures. •. CT rather than plain films is the imaging of choice for suspected craniofacial or skull base fractures. •. Ultrasound, MRI, angiography and other radiological techniques have a role in the evaluation of soft tissue complications of facial and skull base trauma. •. It is useful to approach facial and skull base fractures using an anatomical framework comprising mandibular, central/lateral midface, orbital, craniofacial, middle skull base and temporal bone fractures. •. Neurovascular damage and dural injury leading to cerebrospinal fluid leak and meningitis are key complications of skull base fractures. We review the imaging techniques and protocols used to investigate facial and skull base trauma. Fractures will be classified as mandibular, central midface, lateral midface, orbital, craniofacial, middle skull base and temporal bone fractures. Typical fracture patterns, clinically important features and anticipated soft tissue complications will be emphasised and illustrated.

Frequency and pattern of skull base and vault fracture in isolated head trauma.

Which Craniofacial Fractures Are Associated With External Auditory Canal Bleeding?

Head and neck injury patterns in fatal falls: Epidemiologic and biomechanical considerations

1. Jeff E. Schunk, MD* 2. Sara A. Schutzman, MD† 1. *Professor, Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Utah School of Medicine, Primary Children’s Medical Center, Salt Lake City, UT. 2. †Assistant Professor, Department of Pediatrics, Harvard Medical School, Senior Associate Physician in Medicine, Division of Emergency Medicine, Department of Medicine, Children’s Hospital Boston, Boston, MA. * Abbreviations: BSF: : basilar skull fracture CSF: : cerebrospinal fluid CT: : computed tomography EDH: : epidural hemorrhage GCS: : Glasgow Coma Scale ICI: : intracranial injury ICP: : intracranial pressure PECARN: : Pediatric Emergency Care Applied Research Network SAH: : subarachnoid hemorrhage SDH: : subdural hemorrhage TBI: : traumatic brain injury Recent studies have provided updated guidelines for the diagnosis of head injury and the management of patients who experience concussions. A multidisciplinary panel has recently issued new guidelines for return to play after head injury. After reading this article, readers should be able to: 1. Understand the anatomy and pathophysiology relevant to pediatric head injuries. 2. Take an appropriate history, perform an appropriate physical examination, and decide what imaging, if any, is warranted in the case of a child with a head injury. 3. Know the characteristics of the various types of intracranial injuries. 4. Understand the proper management of both minor and severe head injuries in children. Pediatric head injury is extremely common. Although the vast majority of children with head trauma have minor injuries, a small number, even among well-appearing children, will have more serious injuries with the potential for deterioration and significant sequelae. The clinician is challenged to discern which few among the many injured are at high risk for intracranial complications. Clinical symptoms are neither completely sensitive nor specific for significant injury: vomiting may be associated with intracranial injury (ICI), but most children who experience vomiting do not have a complication. Computed tomography (CT) accurately identifies ICIs requiring intervention, but also identifies minor lesions with unclear clinical importance (ie, not requiring intervention) and exposes developing brains to ionizing radiation with the associated risks. Although clinical decision rules determine which children are at highest risk and provide a useful clinical framework, they may not necessarily direct care. Additionally, in this era of reliance on imaging, it is important to remember what the clinical examination tells us regarding brain function, information that …

The present study comprises aretrospective analysis of skull, skull base, and midface fractures in children, to provide clinical orientation for their management. To date, only few data are available on these injuries in this patient group. Data from inpatient cases diagnosed with amidface, skull, or skull base fracture in the Children's Hospital Auf der Bult from 2015 to 2020 were evaluated. Age, gender, fracture mechanism, diagnosis, treatment, and possible complications were analyzed. Data of 224children were grouped into 107cases with nose fractures, 104cases with skull fractures, 9patients with temporal bone fractures, 4patients with rhinobasal fractures, and 2cases with fractures of the orbital floor. Among patients with nose fractures, the average age was 10.9years (64% males), among patients with skull fractures 1.0year (64% males), and in children with skull base fractures 6.0years (85% males). Falls were the most frequent genesis (63%), followed by car accidents, collisions (25%), and violence (10%). Patients with skull fractures underwent sonography in 94% of cases; in 87% the fracture was verified. Patients with nose fractures underwent x‑ray in 92% of cases, or sonography only in 8%; 95% of patients with nose fractures underwent operative repositioning. Typical fracture signs (i.e., hemotympanum, ophthalmic symptoms) or signs of central nervous system involvement (i.e., nausea, amnesia) occurred in 12 of 13children with skull base fractures, and CT was performed in all these cases (none of whom developed acerebrospinal fluid leak). The imaging modality should be selected based on the clinically suspected diagnosis and the course. Most fractures can be sufficiently treated without any permanent sequelae, except for nose fractures, which frequently require operative repositioning.

As advances in prehospital and early hospital care improve survival of the head-injured patient, radiologists are increasingly charged with understanding the myriad skull base fracture management implications conferred by CT. Successfully parlaying knowledge of skull base anatomy and fracture patterns into precise actionable clinical recommendations is a challenging task. The authors aim to provide a pragmatic overview of CT for skull base fractures within the broader context of diagnostic and treatment planning algorithms. Laterobasal, frontobasal, and posterior basal fracture patterns are emphasized. CT often plays a complementary, supportive, or confirmatory role in management of skull base fractures in conjunction with results of physical examination, laboratory testing, and neurosensory evaluation. CT provides prognostic information about short- and long-term risk of cerebrospinal fluid (CSF) leak, encephalocele, meningitis, facial nerve paralysis, hearing and vision loss, cholesteatoma, vascular injuries, and various cranial nerve palsies and syndromes. The radiologist should leverage understanding of specific strengths and limitations of CT to anticipate next steps in the skull base fracture management plan. Additional imaging is warranted to clarify ambiguity (particularly for potential sources of CSF leak); in other cases, clinical and CT criteria alone are sufficient to determine the need for intervention and the choice of surgical approach. The radiologist should be able to envision stepping into a multidisciplinary planning discussion and engaging neurotologists, neuro-ophthalmologists, neurosurgeons, neurointerventionalists, and facial reconstructive surgeons to help synthesize an optimal management plan after reviewing the skull base CT findings at hand. Online supplemental material is available for this article. ©RSNA, 2021.

A retrospective analysis of 268 trauma patients with facial fractures who received computed tomography of the head was undertaken to assess an association with skull base fractures. The incidence of skull base fracture was compared to facial fractures of various anatomic locations. Skull base fractures were significantly increased in orbital wall/rim fractures (36.0%, P = .0823). In contrast, skull base fractures related to orbital floor (27.3%, P = .6191) and maxillary/zygomatic (29.4%, P = .1148) fractures were not significantly greater and were infrequently seen with mandible (4.0%, P = .0454) and nasal (7.7%, P = .0345) fractures. The incidence of skull base fracture was directly associated with the number of facial fractures per patient; one facial fracture (21.0%), two facial fractures (30.4%), and three or more facial fractures (33.3%) (P < .05). The incidence of skull base fractures was related to the location of facial fractures and the number of facial fractures per patient. The results provide additional clinical information to facilitate the prompt detection and diagnoses of skull base fracture.

Basal skull fractures (BSFs) are caused by blunt force trauma, occurring in the temporal, occipital, sphenoid, and/or ethmoid bones. In pediatric severe traumatic brain injury (sTBI), there is a paucity of data on BSFs. Our goal was to investigate the BSF prevalence, anatomy, and association with short-term outcomes in pediatric sTBI. We retrospectively reviewed all severely injured (Injury Severity Score ≥12) pediatric patients (aged <18 years) admitted to our hospital after experiencing an sTBI (Glasgow Coma Scale score ≤8 and head Abbreviated Injury Scale score ≥4). Neuroimaging for all sTBI patients was reviewed for skull fractures. Data were analyzed with both univariate and multivariate techniques. Of the 180 patients with sTBI, 47 had BSFs for a prevalence of 26% (69 BSFs in total; 16 sTBI patients had ≥2 BSFs). The squamous temporal bone was fractured most frequently (n=30/47 sTBI patients with BSFs). Patients with BSFs were heavier and had more facial injuries than those without (p < 0.05) but were similar in all other admission demographics, injury profiles, and clinical characteristics. Cerebrospinal fluid leak was found in 32% (n = 15 of 47) of BSF patients (otorrhea, n = 12; rhinorrhea, n = 1; otorrhea/rhinorrhea, n = 2; p < 0.001). Mortality, acute central diabetes insipidus, and fewer ventilator-free days were associated with BSFs (p < 0.005), whereas in sTBI survivors, BSFs were associated with longer lengths of stay (p < 0.05). Multiple logistic regression showed that BSFs were positively associated with the presence of subarachnoid hemorrhage (odds ratio [OR], 4.00; p = 0.001), contusion (OR, 2.48; p = 0.029), herniation (OR, 3.40; p = 0.037), and cerebral edema (OR, 2.30; p = 0.047) but negatively associated with diffuse axonal injury (OR, 0.20; p = 0.003). BSFs and mortality were strongly associated (OR, 6.87; p = 0.019). BSFs occurred in 26% of pediatric sTBI patients. The temporal bone was fractured in two thirds of sTBI patients with BSFs, and one third was associated with cerebrospinal fluid leaks. BSFs represent a significant linear blunt force and are independent predictors of mortality. Prognostic and epidemiologic study, level III.

Road traffic accidents are a major health problem worldwide resulting frequently in maxillofacial injuries. The purpose of the study was to assess the incidence and spectrum of facial fractures in patients involved in a motor vehicle accident (MVA). Using picture archiving and communication system, all requests for suspected facial trauma were retrieved during a 62-month period; 374 met the inclusion criteria. Two researchers interpreted the multidetector computed tomography images by consensus. The motor vehicles involved were divided into two groups: those involving a passenger car or a larger vehicle and those involving a motorized two-wheeler. Furthermore, the motor vehicle accidents were divided into collisions and run-off-road accidents. Of the 374 patients (aged 15-80, mean 34), 271 (72 %) were male and 103 (28 %) female. Of all patients, 262 (70 %) had a facial or skull base fracture; of these, multiple separate fractures were present in 56 %. Nasal fractures were the most common fractures followed by orbital, skull base, and maxillary fractures. Frontal bone, LeFort, and zygomatic arch fractures were always accompanied by other fractures. Fractures were more frequent in the group of collisions compared with run-off-road accidents. In the two-wheeled group, only 15 % did not have facial or skull base fractures. Fractures often occur in multitudes as 39 % of all patients have multiple facial or skull bone fractures, and thus, emergency radiologists should be familiar with the complexity of the injuries. Negative clear sinus sign and low-energy sentinel injuries should be trusted as indications of undetected injuries in MVA victims.

CSF leak in penetrating skull base injury is relatively rare compared to close head injury involving skull base fracture. We report a 5-year-old boy presented with epistaxis and impacted pencil into the left nostril. The child was hemodynamically stable without any neurological deficit. Intraoperatively, there was a nasal septal defect posteriorly with anterior skull base fracture associated with CSF leak. The pencil was removed from the left nostril and the CSF leak was repaired using harvested abdominal fat under the same setting. Computed Tomography (CT) of the brain showed right cribriform plate fracture with small pneumocranium. Postoperatively, a prophylactic antibiotic was given for seven days and he was discharged well. Subsequent clinic visits up to one-year postoperative period showed no recurrence of the CSF leak. History taking, physical examination and CT imaging give valuable diagnostic values in managing the penetrating skull base injury. Early intervention for removal of the foreign body and repair of the CSF leak is advocated to prevent catastrophic complication.

Correlation between the skull base fracture and the incidence of intracranial hemorrhage in patients with traumatic brain injury

Study objectives: To determine if the complications associated with skull base fractures are increased when nasotracheal intubation is performed in the field. Design: Retrospective, case-control study over a five-year period. Setting: A helicopter service returning to a Level I trauma center. Type of participants: All injured patients treated in the field who had either radiographic or clinical evidence of skull base fractures in whom nasotracheal intubation was attempted (38) compared with all patients with skull base fractures in whom nasotracheal intubation was not attempted (48) and a convenience sample of patients without skull base fractures in whom nasotracheal intubation was attempted (45). Patients with obvious midface motion on initial examination were excluded. Complications of skull base fractures were categorized as cerebral spinal fluid leak of longer than 24 hours and/or meningitis, cranial nerve injury, diabetes insipidus, and intracranial placement of the endotracheal tube. Interventions: Blind nasotracheal intubation was performed by experienced flight nurses. Results: There were no patients in whom an endotracheal tube was placed intracranially. There was no significant difference in complication rate between the two groups with skull base fractures (with nasotracheal intubation, 24%; 95% confidence interval, 11% to 40%; without nasotracheal intubation, 25%; 95% confidence interval, 14% to 40%). The group without skull base fracture had none of the complications usually associated with skull base fractures. Conclusion: Patients with skull base fracture have a significant complication rate (25%). The complications associated with skull base fractures are not markedly increased by attempts at nasotracheal intubation in the field.

Does nasotracheal intubation increase complications in patients with skull base fractures?

Traumatic internal carotid artery (ICA) occlusion is a rare complication of skull base fractures, characterized by high mortality and disability rates, and poor prognosis. Therefore, timely discovery and correct management are crucial for saving the lives of such patients and improving their prognosis. This article retrospectively analyzed the imaging and clinical data of three patients, to explore the imaging characteristics and treatment strategies for carotid artery occlusion, combined with severe skull base fractures. This case included three patients, all male, aged 21, 63, and 16 years. They underwent plain film skull computed tomography (CT) examination at the onset of their illnesses, which revealed fractures at the bases of their skulls. Ultimately, these cases were definitively diagnosed through CT angiography (CTA) examinations. The first patient did not receive surgical treatment, only anticoagulation therapy, and recovered smoothly with no residual limb dysfunction (Case 1). The other two patients both developed intracranial hypertension and underwent decompressive craniectomy. One of these patients had high intracranial pressure and significant brain swelling postoperatively, leading the family to choose to take him home (Case 2). The other patient also underwent decompressive craniectomy and recovered well postoperatively with only mild limb motor dysfunction (Case 3). We retrieved literature from PubMed on skull base fractures causing ICA occlusion to determine the imaging characteristics and treatment strategies for this type of disease. For patients with cranial trauma combined with skull base fractures, it is essential to complete a CTA examination as soon as possible, to screen for blunt cerebrovascular injury.