Surgical management of anterior cranial base fractures with cerebrospinal fluid fistulae: a single-institution experience.

OBJECTIVE The management of cerebrospinal fluid (CSF) fistulae after anterior cranial base fracture remains a surgical challenge. We reviewed our results in the repair of CSF fistulae complicating multiple anterior cranial base fractures via a combined intracranial extradural and intradural approach and describe a treatment algorithm derived from this experience. METHODS We retrospectively reviewed the files of 209 patients with an anterior cranial base fracture complicated by a CSF fistula who were admitted between 1980 and 2003 to Liège State University Hospital. Among those patients, 109 had a persistent CSF leak or radiological signs of an unhealed dural tear. All underwent the same surgical procedure, with combined extradural and intradural closure of the dural tear. RESULTS Of the 109 patients, 98 patients (90%) were cured after the first operation. Persistent postoperative CSF rhinorrhea occurred in 11 patients (10%), necessitating an early complementary surgery via a transsphenoidal approach (7 patients) or a second-look intracranial approach (4 patients). No postoperative neurological deterioration attributable to increasing frontocerebral edema occurred. During the mean follow-up period of 36 months, recurrence of CSF fistula was observed in five patients and required an additional surgical repair procedure. CONCLUSION The closure of CSF fistulae after an anterior cranial base fracture via a combined intracranial extradural and intradural approach, which allows the visualization and repair of the entire anterior base, is safe and effective. It is essentially indicated for patients with extensive bone defects in the cranial base, multiple fractures of the ethmoid bone and the posterior wall of the frontal sinus, cranial nerve involvement, associated lesions necessitating surgery such as intracranial hematomas, and post-traumatic intracranial infection. Rhinorrhea caused by a precisely located small tear may be treated with endoscopy.

[1]  S. Dogan,et al.  Cerebrospinal fluid leakage complicating skull base fractures: analysis of 81 cases , 2005, Neurosurgical Review.

[2]  P. Jabbour,et al.  [Subcranial subfrontal approach for the treatment of extensive cerebrospinal fluid leaks]. , 2002, Neuro-Chirurgie.

[3]  M. Tokyay,et al.  Sella turcica fractures in a trauma series and their clinical significance. , 1995, Surgical neurology.

[4]  N. Khandelwal,et al.  Nomenclature of Frontobasal Trauma: A New Clinicoradiographic Classification , 2006, Plastic and reconstructive surgery.

[5]  Gross Cw,et al.  Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea and skull base defects: a review of twenty-nine cases. , 1994 .

[6]  D. Choi,et al.  Traumatic cerebrospinal fluid leakage: risk factors and the use of prophylactic antibiotics. , 1996, British journal of neurosurgery.

[7]  C. Snyderman,et al.  Endoscopic Repair of Cerebrospinal Fluid Leaks to the Sinonasal Tract: Predictors of Success , 2000, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[8]  M. Eljamel.  Fractures of the middle third of the face and cerebrospinal fluid rhinorrhoea. , 1994, British journal of neurosurgery.

[9]  Early single-stage repair of complex craniofacial trauma. , 1992 .

[10]  D. Locatelli,et al.  Endoscopic Endonasal Approaches for Repair of Cerebrospinal Fluid Leaks: Nine-Year Experience , 2006, Neurosurgery.

[11]  H. Brodie.  Prophylactic antibiotics for posttraumatic cerebrospinal fluid fistulae. A meta-analysis. , 1997, Archives of otolaryngology--head & neck surgery.

[12]  W. Dandy.  PNEUMOCEPHALUS (INTRACRANIAL PENUMATOCELE OR AEROCELE) , 1926 .

[13]  E. R. Savolaine,et al.  Basal skull fracture with traumatic polycranial neuropathy and occluded left carotid artery: significance of fractures along the course of the carotid artery. , 1998, The Journal of trauma.

[14]  J. Schramm,et al.  Diagnosis and treatment of frontobasal skull fractures , 2005, Neurosurgical Review.

[15]  R. Casiano,et al.  Endoscopic Cerebrospinal Fluid Rhinorrhea Repair: Is a Lumbar Drain Necessary? , 1999, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[16]  Anand Vk,et al.  Surgical decisions in the management of cerebrospinal fluid rhinorrhoea. , 1995 .

[17]  B. Eftekhar,et al.  Prophylactic administration of ceftriaxone for the prevention of meningitis after traumatic pneumocephalus: results of a clinical trial. , 2004, Journal of neurosurgery.

[18]  A. Bibas,et al.  Transnasal endoscopic repair of cerebrospinal fluid rhinorrhoea , 2000 .

[19]  A. Wakhloo,et al.  Evaluation of MR imaging, digital subtraction cisternography, and CT cisternography in diagnosing CSF fistula , 1991, Acta Neurochirurgica.

[20]  G. Moore,et al.  Cerebrospinal Fluid Rhinorrhea: A Review of the Literature , 1992, Ear, nose, & throat journal.

[21]  B. Pertuiset,et al.  Traumatic, spontaneous and postoperative CSF rhinorrhea. , 1984, Advances and technical standards in neurosurgery.

[22]  M. Eljamel,et al.  Post-traumatic CSF fistulae, the case for surgical repair. , 1990, British journal of neurosurgery.

[23]  M. Eljamel,et al.  Localization of inactive cerebrospinal fluid fistulas. , 1995, Journal of neurosurgery.

[24]  A. Cerejo,et al.  The galea frontalis myofascial flap in anterior fossa CSF leaks. , 1993, British journal of plastic surgery.

[25]  D. Sakas,et al.  Compound anterior cranial base fractures: classification using computerized tomography scanning as a basis for selection of patients for dural repair. , 1998, Journal of neurosurgery.

[26]  L. Marentette,et al.  Traumatic anterior fossa cerebrospinal fluid fistulae and craniofacial considerations. , 1991, Otolaryngologic clinics of North America.

[27]  I. Saito,et al.  Frontal sinus repair with free autologous bone grafts and fibrin glue. , 2003, Surgical neurology.

[28]  M. Samii,et al.  [Indication and treatment of frontobasal rhinoliquorrhoea from the ent-surgical and neurosurgical point of view (author's transl)]. , 1978, Laryngologie, Rhinologie, Otologie.

[29]  G. Moore,et al.  Extracranial Approaches to the Repair of Cerebrospinal Fluid Rhinorrhea , 1992, Ear, nose, & throat journal.

[30]  A. Yoskovitch,et al.  Endoscopic repair of cerebrospinal fluid rhinorrhea: is it the treatment of choice? , 1999, The Journal of otolaryngology.

[31]  K. Ohno,et al.  Fractures of the floor of the anterior cranial fossa. , 1995, The Journal of trauma.

[32]  B. Schick,et al.  Long-Term Study of Endonasal Duraplasty and Review of the Literature , 2001, The Annals of otology, rhinology, and laryngology.

[33]  W. Lewin.  Cerebrospinal fluid rhinorrhea in nonmissile head injuries. , 1964, Clinical neurosurgery.

[34]  E. Laws,et al.  Spontaneous cerebrospinal fluid rhinorrhea: evolving concepts in diagnosis and surgical management based on the Mayo Clinic experience from 1970 through 1981. , 1985, Neurosurgery.

[35]  C. Snyderman,et al.  Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea: A Meta‐Analysis , 2000, The Laryngoscope.

[36]  R. Delfini,et al.  Severe craniofacial fractures with frontobasal involvement and cerebrospinal fluid fistula: indications for surgical repair. , 2005, Surgical neurology.

[37]  W. Fisher,et al.  Spontaneous Cerebrospinal Fluid Rhinorrhea , 1992, Ear, nose, & throat journal.

[38]  P. Cooper,et al.  Extracranial repair of cerebrospinal fluid fistulas: technique and results in 37 patients. , 1990, Neurosurgery.

[39]  J. Friedman,et al.  Post-traumatic Cerebrospinal Fluid Leakage , 2001, World Journal of Surgery.

[40]  J. Eby,et al.  Craniofacial and skull base trauma. , 2003, The Journal of trauma.

[41]  R. Pascarella,et al.  Traumatic encephalocele related to orbital roof fractures: report of six cases and literature review. , 2002, Surgical neurology.

[42]  T. D. Briant,et al.  Extracranial repair of cerebrospinal fluid fistulae. , 1982, The Journal of otolaryngology.

[43]  R. Bell,et al.  Management of cerebrospinal fluid leak associated with craniomaxillofacial trauma. , 2004, Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons.

[44]  J. Klastersky,et al.  Antimicrobial prophylaxis in patients with rhinorrhea or otorrhea: a double-blind study. , 1976, Surgical neurology.

[45]  G. Oberascher,et al.  Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid Fistula Diagnosis , 2004, The Laryngoscope.

[46]  Shiang-Fu Huang,et al.  Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea and Skull Base Defect: Ten‐Year Experience , 2004, The Laryngoscope.

[47]  R. Bergland,et al.  Cerebrospinal fluid fistula: clinical aspects, techniques of localization, and methods of closure. , 1969, Journal of neurosurgery.

[48]  P. Kubilis,et al.  Antibiotic prophylaxis after basilar skull fractures: a meta-analysis. , 1998, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[49]  T. Calcaterra.  Diagnosis and management of ethmoid cerebrospinal rhinorrhea. , 1985, Otolaryngologic clinics of North America.

[50]  J. Piek.  Surgical treatment of complex traumatic frontobasal lesions: personal experience in 74 patients. , 2000, Neurosurgical focus.

[51]  D. Kennedy,et al.  Endoscopic Repair of Cerebrospinal Fluid Fistulae and Encephaloceles , 1996, The Laryngoscope.

[52]  C. P. Smith,et al.  The use of cancellous bone for frontal sinus obliteration and reconstruction of frontal bony defects. , 1994, Archives of otolaryngology--head & neck surgery.