Fractures Of Anterior Skull Base Research Articles

“Sandwich” Structure in Reconstruction of Traumatic Comminuted Anterior Skull Base Fractures: Surgical Technique and Outcomes

PurposeComminuted fractures of the anterior skull base can easily cause dural damage, leading to cerebrospinal fluid leakage and retrograde infection. Skull base reconstruction is essential. This study aimed to present a novel and simple technique for repairing skull base defects using a self-made fascia-bone fragments-fascia “sandwich” structure made by fascia, fracture fragments, and sutures. MethodFrom 2018 to 2023, we performed self-made sandwich structures for skull reconstruction in 10 patients with anterior skull base comminuted fractures. After debridement, the intracranial bone fragments of the surgical patient were safely removed. In vitro, the bone fragments were spread between two layers of temporal or broad fascia to form a sandwich structure similar to the size of the bone defect, and the periphery was firmly sutured with sutures. The self-made structure was then filled to the defect and fixed with fibrin glue. The periosteum at the top of the forehead was also turned over to the repair area for covering and fixation. Meanwhile, a facial skin cosmetic suture was performed. Finally, we evaluate the feasibility and efficacy of this technique. ResultsAll 10 patients underwent reconstructive surgery using the self-made fascia-fracture fragments-fascia sandwich structure. Five patients with open wounds on the face also underwent cosmetic revisions. No cerebrospinal fluid leakage occurred in all the patients at discharge as well as 3 months later. ConclusionFor patients with comminuted fracture of the anterior skull base, the fascia-bone fragments-fascia structure could repair the skull base and prevent the occurrence of cerebrospinal fluid.

Severe Traumatic Brain Injury Induced Coagulopathy in Pediatric: An Important Lesson with Literature Review

Children with coagulopathy had a greater mortality rate after moderate to severe traumatic brain injury (TBI). The purpose of the current study was to examine the most recent relevant literature in relation to the therapy of TIC in pediatric isolated severe TBI patients. A 5 years old boy presented to emergency department with decrease of consciousness after hit by a motorcycle. He was referred from the district hospital without proper stabilization within 3 hours after the injury. From the blood examination, hemoglobin level was 8.1 g/dl, base deficit -9.9mEq/L with PTT and aPTT no coagulation suggesting coagulopathy. Emergency non-contrast head computed tomography was performed and showed anterior skull base fracture with discontinuity in left squamous suture suggesting a diastases fracture with an air hypodensity lesion in left frontal area suggesting a pneumocephalus. There was also a hyperdense lesion with crescent shape in frontal and interhemispheric region suggesting subdural hematoma. Delayed operation for almost 6 hours was advocated due to transfusion of whole blood and fresh frozen plasma to correct coagulopathy. The operation was successful, the patient was survived but upon 2 years follow up, the patient still wasn’t able to perform normal daily activity. Localized injury at the brain manifesting in systemic coagulopathy requires special care. Several steps need to be evaluated before surgery but it should not delay the attempt of controlling the source of coagulopathy by it means lesion in the brain. Our case demonstrates the important of recognizing and managing coagulopathy in severe traumatic brain injury.

Epidemiology of Anterior and Lateral Basilar Skull Fractures With CSF Leak: A National Trauma Data Bank Analysis.

Cerebrospinal fluid (CSF) leaks are a complication from dural violations that can occur in the setting of skull base fractures. No prior study provides a nationwide epidemiological analysis of traumatic CSF leaks. The objective of this report is to characterize patient demographics, injury-related variables, and operative management. The national trauma data bank was queried for both anterior and lateral skull base fracture cases between 2008 and 2016. Clinical data were extracted. A total of 242 skull base fractures with CSF leak were identified. Most patients were male (84.3%), and the median patient age was 39.7±17.6 years old. Glasgow Coma Scale was 14.0 [interquartile range (IQR): 6.5-10.6] for lateral fractures, 13.0 (IQR: 3.0-10.0) for anterior fractures, and severe range for combined fractures at 7.0 (IQR: 5.0-9.0) (analysis of variance, P =0.122). Common mechanisms of injury were motor vehicle accidents (107, 44.2%), followed by falls and firearms (65, 26.9% and 20, 8.3%, respectively). The median length of stay was 2 weeks, with a median of 14 days (IQR: 10-25) for the anterior fractures and 10 days (IQR 5-19) among the lateral fractures ( P =0.592). Patients were most commonly discharged home in both the anterior (43.8%) and lateral (49.2%) groups. The prototypical patient tends to be a young adult male presenting with moderate-to-severe range neurological dysfunction after a vehicular accident. The overall prognosis of skull base fractures with CSF leak remains encouraging, with nearly half of these patients being discharged home within 2 weeks.

Characteristics and clinical findings of traumatic brain injury patients in single referral hospital dr. Hasan Sadikin hospital, Bandung, West Java, Indonesia

Introduction: Traumatic brain injury (TBI) is the leading cause of mortality and morbidity in children and young adults globally. Knowledge of TBI characteristics holds importance on the treatment improvement of and scientific progression. Thus, this study aimed to evaluate the characteristics of TBI in Hasan Sadikin Hospital.Methods: Analysis of data obtained from a retrospective review of medical records and from a systematic database pertaining to diagnostic criteria of TBI treated in the Department of Neurosurgery at Dr. Hasan Sadikin Hospital, Bandung, Indonesia from January 1st 2012 to December 31st 2018.Results: This study included 10,234 cases over the described time period. Men had a higher prevalence of TBI (7,539 patients or 73.7%) compared to women (2,695 patients or 26.7%). The majority of the cases were mild TBI (68.3%). The most common skull fracture was linear fracture (68.6%), while the majority of skull base fracture was anterior skull base fracture (66.7%). The majority of intracranial lesions were cerebral contusion (26.4%). Intracranial lesions were commonly observed in patients with moderate or severe than mild TBI.Conclusion: The incidence of accompanying intracranial lesions and skull fracture were commonly observed in patients with moderate or severe TBI than patients with mild TBI.Keywords: alcohol intoxication, intracranial lesions, skull base fracture, skull fracture, traumatic brain injury

Treatment of traumatic cerebrospinal fluid rhinorrhea via extended extradural anterior skull base approach

ObjectiveTo describe and assess the repair technique and perioperative management for cerebrospinal fluid (CSF) leak resulting from extensive anterior skull base fracture via extradural anterior skull base approach. MethodsThis was a retrospective review conducted at the Department of Neurosurgery of the Shanghai Tenth People's Hospital from January 2015 to April 2020. Patients with traumatic CSF rhinorrhea resulting from extensive anterior skull base fracture treated surgically via extended extradural anterior skull base approach were included in this study. The data of medical and radiological records, surgical approaches, repair techniques, peritoperative management, surgical outcome and postoperative follow-up were analyzed. Surgical repair techniques were tailored to the condition of associated injuries of the scalp, bony and dura injuries and associated intracranial lesions. Patients were followed up for the outcome of CSF leak and surgical complications. Data were presented as frequency and percent. ResultsThirty-five patients were included in this series. The patients’ mean age was 33 years (range 11–71 years). Eight patients were treated surgically within 2 weeks; while the other 27 patients, with prolonged or recurrent CSF rhinorrhea, received the repair surgery at 17 days to 10 years after the initial trauma. The mean overall length of follow-up was 23 months (range 3–65 months). All the patients suffered from frontobasal multiple fractures. The basic repair tenet was to achieve watertight seal of the dura. The frontal pericranial flap alone was used in 20 patients, combined with temporalis muscle and/or its facia in 10 patients. Free fascia lata graft was used instead in the rest 5 patients. No CSF leak was found in all the patients at discharge. There was no surgical mortality in this series. Bilateral anosmia was the most common complication. At follow-up, no recurrent CSF leak or meningitis occurred. No patients developed mucoceles, epidural abscess or osteomyelitis. One patient ultimately required ventriculoperitoneal shunt because of progressive hydrocephalus. ConclusionTraumatic CSF rhinorrhea associated with extensive anterior skull base fractures often requires aggressive treatment via extended intracranial extradural approach. Vascularized tissue flaps are ideal grafts for cranial base reconstruction, either alone or in combination with temporalis muscle and its fascia---fascia lata sometimes can be opted as free autologous graft. The approach is usually reserved for patients with traumatic CSF rhinorrhea in complex frontobasal injuries.

Combined Transcranial-endonasal Reconstructive Surgery for Cerebrospinal Fluid Leakage Resulting from Traumatic Anterior Skull Base Fractures Involving the Parasellar Region.

Extensive traumatic anterior skull base fractures from the frontal sinus to the parasellar region are frequently accompanied by multiple dural defects that cause persistent cerebrospinal fluid (CSF) leakage. Conventional transcranial reconstruction using a frontal periosteal flap is frequently insufficient, and parasellar dural defects are often deep, complex, and difficult to identify. In this report, we describe a combined transcranial–endonasal reconstructive technique and report our experience. Simultaneous combined transcranial and endoscopic surgery was performed in three patients with CSF leakage resulting from traumatic anterior skull base fractures. Dural defects were thoroughly identified from the transcranial and endonasal surgical fields, and covered using a multilayer sealing technique. The anterior regions of the anterior skull base were reconstructed using a free fascial flap and frontal periosteal flap; posterior and parasellar regions were reconstructed using a fat graft, vascularized nasoseptal flap, and endonasal balloon. Suturing the transcranial grafts to the parasellar dura mater was performed collaboratively by the transcranial and endonasal surgeons. In our cases, complete cessation of CSF leakage was achieved without perioperative lumbar drainage in all patients. Mean time to postoperative ambulation was 7 days (range, 3–11). No surgical complications occurred. Simultaneous transcranial and endonasal procedures were helpful to detect all sites of CSF leakage and secure reconstructive grafts. The combined transcranial and endonasal reconstructive technique achieved secure skull base reconstruction without recurrence of CSF leakage, and allowed early postoperative ambulation. This technique can be a reliable surgical option to repair CSF leakage resulting from extensive anterior skull base fractures.

Orbito-Cranial Gunshot Injuries with Retained Sinonasal Bullets.

Gunshot injuries to the sino-orbital region are rare. In South Africa, where gunshot injuries are common, sino-orbital gunshot injuries are encountered. Sino-orbital gunshot injuries are associated with trauma to surrounding facial and intracranial structures. Therefore, the management of these injuries may be complex and often requires an interdisciplinary approach. To review the management of orbito-cranial gunshot injuries with retained sinonasal bullets. Three cases of orbito-cranial gunshot injuries with retained sinonasal bullets were reviewed. Two cases were complicated by cerebrospinal fluid leaks with ensuing meningitis. The retained bullets in all three cases were successfully removed via a transnasal endoscopic approach. Sino-orbital gunshot injuries are rare, but may be encountered in areas with high frequencies of gun violence. An associated anterior skull base fracture with CSF rhinorrhoea poses a risk for meningitis and a low threshold for diagnosis and treatment of meningitis should be maintained. Retained bullets in the paranasal sinuses do not pose an immediate risk and may be removed on an elective basis.

Impact of anterior skull base fracture on lateralized olfactory function.

Data on the impact of anterior skull base fractures (aSBF) on lateralized olfactory function are missing. The goal of the study was to investigate olfactory function in patients with traumatic brain injury (TBI) due to aSBF separately for each side and assess the frequency of lateralized smell impairment. Retrospective, single center study of olfactory function in 93 patients with aSBF. Olfactory function was assessed by means of the Sniffin' Sticks test battery for each side of the nose, separately. TBI severity was graded according to the Glasgow Coma Scale. Average time interval between olfactory test and trauma was 6.5 years. General olfactory function was defined as the best side out of both nostrils. A total of 50 patients had unilateral and 43 patients bilateral aSBF. The grade of TBI was inversely correlated with olfactory function. General olfactory function was significantly worse in patients with bilateral aSBF compared to patients with unilateral aSBF. Clinically significant side by side differences in olfactory function were found in 18 and 30% respectively for unilateral and bilateral aSBF. Grade of TBI had no significant impact on side differences. Among patients with unilateral aSBF olfactory function was not significantly different between the fractured and the non-fractured side. The severity of TBI and bilateral more than unilateral aSBF results in more impaired olfactory function. Lateralized olfactory deficits were not more frequent in any group, regardless of the fracture type and side.

Traumatic chiasmal syndrome: A meta-analysis

PurposeTo report a case presenting with bitemporal hemianopia due to traumatic chiasmal syndrome after head injury, and to compare the findings with individual case reports published in the literature. MethodsA detailed search was made in PubMed, MedIND, Taylor and Francis online and Wiley online library databases for individual case reports of traumatic chiasmal syndrome. All the case reports were read in full and the findings summarized in a table, which included details of the case who presented with bitemporal hemianopia as an index case. ResultsAll published cases of traumatic chiasmal syndrome appear to share some common features, such as injury to the frontal bone and fracture of the anterior skull base. Bitemporal hemianopia and visual acuity have a variable presentation, and do not appear to correlate with severity of injury. Isolated bitemporal hemianopia is rare and clinical improvement may or may not occur. Conclusions and importanceTraumatic chiasmal syndrome should be considered as a differential diagnosis in patients presenting with bitemporal hemianopia after head injury causing frontal and anterior skull base fracture.

One-stage reconstruction surgery for pediatric comminuted and depressed fractures of frontal bone and anterior skull base

Objective To explore the surgical techniques and effects of one-stage reconstruction surgery for pediatric comminuted and depressed fractures of frontal bone and anterior skull base. Methods The clinical data of 13 pediatric cases with one-stage reconstruction surgery for comminuted and depressed fractures of the frontal bone and anterior skull base were reviewed retrospectively, including 8 male and 5 female, aged from 4 to 14 years, with a mean age of 8 years.Admission Glasgow Coma Scale (GCS) was as follows: 3 to 8 scores in 2 cases, 9 to 11 scores in 4 cases, and 12 to 15 scores in 7 cases.The intraoperative one- stage osseous and vascular pedicle membranous reconstruction of frontal bone and anterior skull base had been performed in all patients.The periosteum-bone fragments-periosteum had been used in 4 cases whose bony defect diameter of anterior cranial fossa was over 1 cm, multimodality therapy were carried out postoperatively.The follow-ups were regularly executed after discharge. Results GCS at discharge was as follows: 3 to 8 scores in 1 case, 9 to 11 scores in 2 cases, and 12 to 15 scores in 10 cases.No significant difference was found in GCS between those on admission and at discharge(χ2=3.02, P>0.05). Eleven cases had a phenomenon of nasal hemorrhage and the duration was not exceeding 48 hours.No intracranial infection and cerebrospinal fluid leakage occurred in all patients.All patients received an acceptable appearance without obvious frontal depre-ssion or proptosis.Postoperative computed tomography image showed normal cranial volume, well reset of fracture pieces, no fracture pieces existing in intracerebral tissue, satisfactory hematoma evacuation, and orbital contents without compression.The complications like cerebrospinal fluid leakage, poor incision healing, brain abscess or mucous cyst had not been found in all patients from 3 months to 6 years follow-up period. Conclusions The one-stage reconstruction surgery for pediatric comminuted and depressed fractures of frontal bone and anterior skull base suggests a better prognosis, effectively less complications, which helps to avoid secondary surgery, but regular follow-ups are absolutely necessary.This procedure is worth applying and spreading to pediatric patients and medical institutions if necessary. Key words: One-stage reconstruction; Comminuted and depressed fracture; Frontal bone; Anterior skull base; Child

Complex Anterior Skullbase Fracture Caused by a Bottle Cap: A Case Report and Review of the Literature

We report a case of foreign body presence in the ethmoid sinus cavity with anterior skull base fracture and visual loss. A 42-year-old male had an uncertain history of trauma and a penetrating wound near the left medial canthus. Computed tomography imaging showed a 3.0-cm bottle cap penetrating into the anterior skull base. He underwent foreign body removal, canalicular repair, ethmoidectomy, and cerebrospinal fluid leakage repair using packing material. Six months after the initial surgery, a second-stage operation for blow-out fracture repair was performed. At the 18-month postoperative follow-up from the initial surgery, the patient had no complaints except anosmia. This is a very rare case of a large, blunt, foreign body penetrating into the anterior skull base without long-term complications after successful removal and skull base repair. Simultaneous repair of cerebrospinal fluid leakage, management of canaliculi injury, and traumatic optic nerve neuropathy should be considered in such cases.

Clinical significance of skull base fracture in patients after traumatic brain injury

About 4% of all head injuries include skull base fractures. Most of these fractures (90%) are secondary to closed head trauma; the remainder are due to penetrating trauma. We reviewed the records from January 2006 through December 2008 of all patients older than 18years of age who arrived at Soroka Medical Center in Be’er-Sheva, Israel, with skull base fractures following a traumatic brain injury (TBI). We identified 107 patients with a mean age of 42years at the time of TBI. Glasgow Coma score on arrival predicted the clinical outcome. We observed temporal fractures in 30% of these patients, occipital fractures in 20%, pyramidal fractures in 19%, anterior skull base fractures in 17%, and multiple fractures in 14%. Cerebrospinal fluid (CSF) leak was observed in 16 patients (15%). Of the patients experiencing CSF leaks, otorrhea occurred in 10 (62%) and rhinorrhea occurred in six (37%). Three patients required surgical intervention to repair the leak. Meningitis occurred in four patients with clinically evident CSF leak. Multiple skull base fractures are associated with poor neurological outcome. The low rate of meningitis in this patient sample implies that there is no indication to administer prophylactic antibiotics to patients with skull base fractures.

Trauma of the midface.

Fractures of the midface pose a serious medical problem as for their complexity, frequency and their socio-economic impact. Interdisciplinary approaches and up-to-date diagnostic and surgical techniques provide favorable results in the majority of cases though. Traffic accidents are the leading cause and male adults in their thirties are affected most often. Treatment algorithms for nasal bone fractures, maxillary and zygomatic fractures are widely agreed upon whereas trauma to the frontal sinus and the orbital apex are matter of current debate. Advances in endoscopic surgery and limitations of evidence based gain of knowledge are matters that are focused on in the corresponding chapter. As for the fractures of the frontal sinus a strong tendency towards minimized approaches can be seen. Obliteration and cranialization seem to decrease in numbers. Some critical remarks in terms of high dose methylprednisolone therapy for traumatic optic nerve injury seem to be appropriate. Intraoperative cone beam radiographs and preshaped titanium mesh implants for orbital reconstruction are new techniques and essential aspects in midface traumatology. Fractures of the anterior skull base with cerebrospinal fluid leaks show very promising results in endonasal endoscopic repair.

Extensive traumatic anterior skull base fractures with cerebrospinal fluid leak: classification and repair techniques using combined vascularized tissue flaps.

This article introduces a classification scheme for extensive traumatic anterior skull base fracture to help stratify surgical treatment options. The authors describe their multilayer repair technique for cerebrospinal fluid (CSF) leak resulting from extensive anterior skull base fracture using a combination of laterally pediculated temporalis fascial-pericranial, nasoseptal-pericranial, and anterior pericranial flaps. Retrospective chart review identified patients treated surgically between January 2004 and May 2014 for anterior skull base fractures with CSF fistulas. All patients were treated with bifrontal craniotomy and received pedicled tissue flaps. Cases were classified according to the extent of fracture: Class I (frontal bone/sinus involvement only); Class II (extent of involvement to ethmoid cribriform plate); and Class III (extent of involvement to sphenoid bone/sinus). Surgical repair techniques were tailored to the types of fractures. Patients were assessed for CSF leak at follow-up. The Fisher exact test was applied to investigate whether the repair techniques were associated with persistent postoperative CSF leak. Forty-three patients were identified in this series. Thirty-seven (86%) were male. The patients' mean age was 33 years (range 11-79 years). The mean overall length of follow-up was 14 months (range 5-45 months). Six fractures were classified as Class I, 8 as Class II, and 29 as Class III. The anterior pericranial flap alone was used in 33 patients (77%). Multiple flaps were used in 10 patients (3 salvage) (28%)--1 with Class II and 9 with Class III fractures. Five (17%) of the 30 patients with Class II or III fractures who received only a single anterior pericranial flap had persistent CSF leak (p < 0.31). No CSF leak was found in patients who received multiple flaps. Although postoperative CSF leak occurred only in high-grade fractures with single anterior flap repair, this finding was not significant. Extensive anterior skull base fractures often require aggressive treatment to provide the greatest long-term functional and cosmetic benefits. Several vascularized tissue flaps can be used, either alone or in combination. Vascularized flaps are an ideal substrate for cranial base repair. Dual and triple flap techniques that combine the use of various anterior, lateral, and nasoseptal flaps allow for a comprehensive arsenal in multilayered skull base repair and salvage therapy for extensive and severe fractures.

Management Strategies for Communited Fractures of Frontal Skull Base: An Institutional Experience

Aim The aim of this study is to present our experience in management of complex, communited fractures of the frontal skull base. Patients and Methods This was a retrospective study performed between January 2000 to January 2013. Data of 1,935 patients with head trauma operated in our department during this period were analyzed. Overall, 210 patients with compound anterior skull base fractures were reviewed. Patients were classified based on radiological features in three groups. Standard neurosurgical protocol was followed for all patients after trauma; reconstruction using titanium mesh, miniplates, and silastic graft was done 6 months to 1 year later. Conclusion Frontal depressed fractures involving the anterior cranial base are complex and require a definitive plan of approach. Reconstruction of bony and dural defects reduces cerebrospinal fluid leak, brain herniation, and infection. Cosmetic reconstruction of the frontal deformity is necessary at a later stage.

Extensive Anterior Cranial Base Fractures: Anatomic and Surgical Description of Combination Flaps

Introduction: Traditionally, cerebrospinal fluid (CSF) fistula repair following anterior skull base fractures has been accomplished with the use of exclusive anterior-based pericranial flaps. Over time, limitations have been identified with this technique. Persistent CSF leak rates following initial repairs are 12.5 to 17%, and could potentially be contributed to compromise blood supply resulting from initial cranial insult. In addition, glabellar tissue defects from placement of these flaps can result in poor cosmesis. The limited posterior reach of these flaps can hinder repairs in fractures with a substantial posterior extent. This has led to the addition of lateral temporoparital fascial flap and nasoseptal flap to our repair techniques.

Classification and Repair of Extensive Anterior Skull Base Fractures

Classification and Repair of Extensive Anterior Skull Base Fractures

Frontobasilar fractures: Proposal for image reviewing algorithm

ObjectiveThe aim of this study was to develop and test the utility of a novel systematic protocol to analyze CT images of patients with trauma in the anterior cranial base and upper midface. Material and MethodsThe radiological data and primary reports of 27 consecutive patients with a frontal skull base fracture treated in two tertiary care hospitals from 2007 to 2011 were scrutinized. A novel algorithm for systematic image reviewing was used to assess the CT images and the findings were compared with the primary radiological reports. ResultsThe systematic review detected a substantial number of fractures and defects in anatomical structures that had not been systematically reported in the primary, on-call reports. Anterior skull base fracture was not initially reported in 32% of the patients; however, the algorithm detected this in 93% of them. The corresponding rates for fracture through cribriform plate were 28% and 72% and for fracture through the sella or hypophyseal area 22% and 78%. There were two fractures of the clivus and these were initially missed. ConclusionsDespite the failure to identify these fractures radiologically in the primary setting, all patients were still considered to have received appropriate treatment, but, the use of an image-reviewing algorithm will enhance the specificity of CT in the diagnosis of frontobasilar fractures.

Anterior Skull Base Traumas and Their Management

We read with interest the article written by Piccirilli et al (J Neurol Surg B 2012;73:265-272) regarding their retrospective study about the management of anterior cranial fossa traumas. Even if frontal skull base fractures represent one of the most dangerous consequences after brain injury, there are no guidelines or evidence-based data about the best surgical or conservative management. The authors attempted to introduce an attractive classification of anterior skull base fractures into three types. However, this classification presents some problems. In fact, as shown in Fig. 4 of the above mentioned article, a common issue with these injuries is the involvement of the orbit. If the orbital roof, the orbital lateral wall, or the medial wall is involved, management should be tailored with involvement of different disciplines (e.g., ophthalmology, ear/nose/throat [ENT], or maxillofacial surgery), as well as with different kinds of approaches. Our proposal is to include in the classification a subtype with or without orbital involvement. Regarding the treatment options of the different types of fractures, we agree with the authors that the surgical management of Type A fractures should be considered optional. However, we disagree with the authors regarding the proposed treatment options in type B and C fractures. In fact, in our experience, the presence of a fissure of the internal wall of the frontal sinus or a basal fracture near the lamina cribrosa always represents a surgical indication, even in the absence of evident rhinoliquorrhea. Actually, the intradural subfrontal inspection of these cases reveals in most cases tiny dural gaps, often near the crista galli, which must be repaired and/or covered. These small leaks are generally neglected or undetected in the actual magnetic resonance imaging (MRI) and computed tomography (CT) scans. We have observed that lack of awareness of this condition may have serious consequences, like chronic meningitis, delayed intracranial abscesses, or empyemas, which can develop after decades. These experiences lead us to give a surgical indication for all the cases described in the discussed article as type B and C and to always perform an intradural subfrontal inspection, ultimately covering or repairing any dural tear. The choice to perform it through a unilateral or a bilateral approach depends on the extent of the damage.

Suggesting Caution for Pneumocephalus and Anterior Skull Base Fracture in the Setting of Epistaxis after Head Injury

Pneumocephalus is common after neurosurgical and sinus procedures, but also after traumatic base of skull fractures. An elderly woman presented after a fall with epistaxis, confusion, and progressive conscious decline. CT showed a right-sided cribriform plate fracture and severe pneumocephalus involving the extradural, subdural, intraventricular, and posterior fossa compartments. It was postulated the “epistaxis” was a blood-stained CSF leak, which allowed the intracranial pressure to drop, encouraging air to enter the subarachnoid/subdural space by means of a dehiscence in the skull base, creating a CSF fistula. We hereby describe a distinct radiological entity, the “twin peaks” sign, which should not be confused with the mount Fuji sign. In the latter, the frontal lobes are collapsed by pneumocephalus in the convexity of each hemisphere. The significance of the twin peaks sign is twofold: (1) The frontal lobes collapse, like in the Mount Fuji sign, but there is, in addition, air entrapment in the interhemispheric space, which may lead to compression from the center outward as well as to compression from the convexity inward. (2) The separation of the frontal lobes beyond the point of their tips, causing these prominent peaks, is a sign of increased tension. This suggests the air pressure is at least greater than that of the surface tension of cerebrospinal fluid between the frontal lobes. It also suggests the bridging veins are not intact. Epistaxis in the setting of head injury, whether severe or mild and repetitive, should alert to the possibility of CSF leak and skull base fracture. Progressive neurological decline should prompt investigations to exclude tension pneumocephalus. The twin peaks sign should lead to immediate referral to neurosurgery.