Management of Skull Base Fractures

Abstract

The risk of developing an intracranial complication after head injury is greater in those who have sustained a skull fracture. Fractures of the basis cranii are usually the result of extension of a vault fracture. The most important complications of these fractures are cerebrospinal fluid (CSF) fistula, related infection and pneumocephalus with fistula, and cranial nerve and intracranial major vessel injury. Although CSF fistulas and posttraumatic meningitis have been discussed extensively in the literature, neurovascular complications of basilar skull fractures have not been so well described. Posttraumatic evaluation and management of basal skull fractures have not yet been standardized. Here, we have classified basal skull fractures according to site and evaluated the posttraumatic complications. Anterior and middle cranial base fractures generally cause upper cranial nerve injuries (I, II, III, IV, V, and VI) and vascular injuries to the carotid artery and middle cerebral artery. Posterior cranial base fractures are associated with injury to the lower cranial nerves (IX, X, XI, and XII) and major venous sinuses. Laterobasal fractures, including those of the petrous bone, are usually associated with deficits of facial and vestibulocochlear nerves (VII and VIII). Controversies in the management of skull base fractures and related complications have gained little attention in medical practice. Many authors have discussed prophylactic antibiotic therapy for CSF fistulas caused by basal skull fractures, but there has not been a standardized protocol for CSF leak management. Early evaluation of skull base fractures and related complications has been discussed in many articles, but the timing of surgical interventions for basal skull fractures and related complications has not been standardized.