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

Post-discharge 6-Month Functional Recovery of Traumatic Brain Injury Survivors with Unfavorable Functional Status at Discharge: A Registry-Based Cohort Study

BACKGROUND

Traumatic brain injury (TBI) is a major cause of physical disabilities worldwide. Herein, we aimed to investigate the factors contributing to post-discharge recovery in patients who were discharged with an unfavorable outcome.

METHODS

We collected data on the characteristics of patients, with a focus on those who survived TBI but had an unfavorable outcome at discharge as measured by Glasgow Outcome Scale Extended (GOSE) categories 2, 3, and 4. Post-discharge recovery was defined as achieving a favorable functional status at 6 months (GOSE of 5 or more) with a minimum 2-point increase in GOSE.

RESULTS

Of 4011 TBI patients in our registry, 797 had an unfavorable discharge functional status. In severe TBI, 51% achieved recovery, while in mild to moderate TBI, 57% achieved recovery after 6 months. Older patients and those with shorter intensive care unit length of stay were more likely to experience post-discharge recovery in both mild to moderate and severe TBI groups. The presence of skull base fracture was also associated with post-discharge recovery in severe TBI patients. Lastly, we show that, after adjustment for potential confounders, GOSE at discharge is associated with post-discharge recovery in both mild to moderate and severe TBI patients.

CONCLUSIONS

This study found that the majority of patients discharged with an unfavorable functional status were able to achieve a favorable outcome within 6 months. The novel post-discharge recovery in TBI patients might be a useful tool for illuminating the factors associated with a significant improvement after discharge.

[Neurosurgical Management of Traumatic Brain Injury]

The neurosurgical management of traumatic brain injury (TBI) plays a critical role in ensuring acute survival and mitigating secondary brain damage, which significantly impacts patients' quality of life. TBI is defined as an external force impacting the skull, leading to brain injuries and subsequent functional impairments. It is a leading cause of mortality and morbidity, particularly among young individuals. The initial clinical examination is crucial, with external signs like scalp injuries, hematomas, nasal fluid leakage, skull deformities, and neurological deficits providing important clues to injury patterns. Pupil examination is particularly critical, as mydriasis coupled with reduced consciousness may indicate an acute life-threatening increase in intracranial pressure (ICP), necessitating immediate neurosurgical intervention. TBI assessment often utilizes the Glasgow Coma Scale (GCS), classifying injuries as mild (GCS 13-15), moderate (GCS 9-12), or severe (GCS < 9). Even mild TBI can lead to long-term complications. TBI should be viewed as a disease process rather than a singular event. Primary brain damage results from shearing forces on the parenchyma, manifesting as contusions, hematomas, or diffuse axonal injury. Secondary brain damage is driven by mechanisms such as inflammation and spreading depolarizations. Treatment aims not only to secure immediate survival but also to reduce secondary injuries, with ICP management being crucial. Neurosurgical interventions are guided by cranial pathologies, with options including ICP monitoring, burr hole trepanation, craniotomy. In severe TBI cases with refractory ICP elevation, decompressive craniectomy may be performed as a last resort, significantly reducing mortality but often resulting in high morbidity and vegetative states, necessitating careful consideration of indications.

The emerging importance of skull-brain interactions in traumatic brain injury

The recent identification of skull bone marrow as a reactive hematopoietic niche that can contribute to and direct leukocyte trafficking into the meninges and brain has transformed our view of this bone structure from a solid, protective casing to a living, dynamic tissue poised to modulate brain homeostasis and neuroinflammation. This emerging concept may be highly relevant to injuries that directly impact the skull such as in traumatic brain injury (TBI). From mild concussion to severe contusion with skull fracturing, the bone marrow response of this local myeloid cell reservoir has the potential to impact not just the acute inflammatory response in the brain, but also the remodeling of the calvarium itself, influencing its response to future head impacts. If we borrow understanding from recent discoveries in other CNS immunological niches and extend them to this nascent, but growing, subfield of neuroimmunology, it is not unreasonable to consider the hematopoietic compartment in the skull may similarly play an important role in health, aging, and neurodegenerative disease following TBI. This literature review briefly summarizes the traditional role of the skull in TBI and offers some additional insights into skull-brain interactions and their potential role in affecting secondary neuroinflammation and injury outcomes.

Clinical Management in Traumatic Brain Injury

Traumatic brain injury is one of the leading causes of morbidity and mortality worldwide and is one of the major public healthcare burdens in the US, with millions of patients suffering from the traumatic brain injury itself (approximately 1.6 million/year) or its repercussions (2-6 million patients with disabilities). The severity of traumatic brain injury can range from mild transient neurological dysfunction or impairment to severe profound disability that leaves patients completely non-functional. Indications for treatment differ based on the injury's severity, but one of the goals of early treatment is to prevent secondary brain injury. Hemodynamic stability, monitoring and treatment of intracranial pressure, maintenance of cerebral perfusion pressure, support of adequate oxygenation and ventilation, administration of hyperosmolar agents and/or sedatives, nutritional support, and seizure prophylaxis are the mainstays of medical treatment for severe traumatic brain injury. Surgical management options include decompressive craniectomy or cerebrospinal fluid drainage via the insertion of an external ventricular drain. Several emerging treatment modalities are being investigated, such as anti-excitotoxic agents, anti-ischemic and cerebral dysregulation agents, S100B protein, erythropoietin, endogenous neuroprotectors, anti-inflammatory agents, and stem cell and neuronal restoration agents, among others.

Ten-Year Analysis of Complications Related to Simple Basilar Skull Fractures in Children Presenting to a Trauma Center

OBJECTIVES

Head trauma is a common presenting complaint among children requiring urgent medical attention, accounting for more than 600,000 emergency department (ED) visits annually, 4% to 30% of which identify skull fractures among the patient's injuries. Previous literature shows that children with basilar skull fractures (BSFs) are usually admitted for observation. We studied whether children with an isolated BSF have complications precluding them from safe discharge home from the ED.

METHODS

We performed a retrospective review of ED patients aged 0 to 18 years given a simple BSF diagnosis (defined by nondisplaced fracture, with normal neurologic examination, Glasgow Coma Score of 15, no intracranial hemorrhage, no pneumocephalus) during a 10-year period to identify complications associated with their injury. Complications were defined as death, vascular injury, delayed intracranial hemorrhage, sinus thrombosis, or meningitis. We also considered hospital length of stay (LOS) longer than 24 hours or any return visit within 3 weeks of the original injury.

RESULTS

Of the 174 patients included in the analysis, there were no deaths, cases of meningitis, vascular injury, nor delayed bleeding events. Thirty (17.2%) patients required a hospital LOS longer than 24 hours and 9 (5.2%) returned to the hospital within 3 weeks of discharge. Of those with LOS longer than 24 hours, 22 (12.6%) patients needed subspecialty consultation or intravenous fluids, 3 (1.7%) had cerebrospinal fluid leak, and 2 (1.2%) had a concern for facial nerve abnormality. On the return visits, only 1 (0.6%) patient required readmission for intravenous fluids because of nausea and vomiting.

CONCLUSIONS

Our findings suggest that patients with uncomplicated BSFs can be safely discharged from the ED if the patient has reliable follow-up, is tolerating oral fluids, has no evidence of cerebrospinal fluid leak, and has been evaluated by appropriate subspecialists before discharge.

A Systematic Review on Traumatic Brain Injury Pathophysiology and Role of Herbal Medicines in its Management

BACKGROUND

Traumatic brain injury (TBI) is a worldwide problem. Almost about sixtynine million people sustain TBI each year all over the world. Repetitive TBI linked with increased risk of neurodegenerative disorder such as Parkinson, Alzheimer, traumatic encephalopathy. TBI is characterized by primary and secondary injury and exerts a severe impact on cognitive, behavioral, psychological and other health problem. There were various proposed mechanism to understand complex pathophysiology of TBI but still there is a need to explore more about TBI pathophysiology. There are drugs present for the treatment of TBI in the market but there is still need of more drugs to develop for better and effective treatment of TBI, because no single drug is available which reduces the further progression of this injury.

OBJECTIVE

The main aim and objective of structuring this manuscript is to design, develop and gather detailed data regarding about the pathophysiology of TBI and role of medicinal plants in its treatment.

METHOD

This study is a systematic review conducted between January 1995 to June 2021 in which a consultation of scientific articles from indexed periodicals was carried out in Science Direct, United States National Library of Medicine (Pubmed), Google Scholar, Elsvier, Springer and Bentham.

RESULTS

A total of 54 studies were analyzed, on the basis of literature survey in the research area of TBI.

CONCLUSION

Recent studies have shown the potential of medicinal plants and their chemical constituents against TBI therefore, this review targets the detailed information about the pathophysiology of TBI and role of medicinal plants in its treatment.

Targeting hydrogen sulfide and nitric oxide to repair cardiovascular injury after trauma

The systemic cardiovascular effects of major trauma, especially neurotrauma, contribute to death and permanent disability in trauma patients and treatments are needed to improve outcomes. In some trauma patients, dysfunction of the autonomic nervous system produces a state of adrenergic overstimulation, causing either a sustained elevation in catecholamines (sympathetic storm) or oscillating bursts of paroxysmal sympathetic hyperactivity. Trauma can also activate innate immune responses that release cytokines and damage-associated molecular patterns into the circulation. This combination of altered autonomic nervous system function and widespread systemic inflammation produces secondary cardiovascular injury, including hypertension, damage to cardiac tissue, vascular endothelial dysfunction, coagulopathy and multiorgan failure. The gasotransmitters nitric oxide (NO) and hydrogen sulfide (H2S) are small gaseous molecules with potent effects on vascular tone regulation. Exogenous NO (inhaled) has potential therapeutic benefit in cardio-cerebrovascular diseases, but limited data suggests potential efficacy in traumatic brain injury (TBI). H2S is a modulator of NO signaling and autonomic nervous system function that has also been used as a drug for cardio-cerebrovascular diseases. The inhaled gases NO and H2S are potential treatments to restore cardio-cerebrovascular function in the post-trauma period.

Fracture R-CNN: An anchor-efficient anti-interference framework for skull fracture detection in CT images

BACKGROUND

Skull fracture, as a common traumatic brain injury, can lead to multiple complications including bleeding, leaking of cerebrospinal fluid, infection, and seizures. Automatic skull fracture detection (SFD) is of great importance, especially in emergency medicine.

PURPOSE

Existing algorithms for SFD, developed based on hand-crafted features, suffer from low detection accuracy due to poor generalizability to unseen samples. Deploying deep detectors designed for natural images like Faster Region-based Convolutional Neural Network (R-CNN) for SFD can be helpful but are of high redundancy and with nonnegligible false detections due to the cranial suture and skull base interference. Therefore, we, for the first time, propose an anchor-efficient anti-interference deep learning framework named Fracture R-CNN for accurate SFD with low computational cost.

METHODS

The proposed Fracture R-CNN is developed by incorporating the prior knowledge utilized in clinical diagnosis into the original Faster R-CNN. Specifically, based on the distributions of skull fractures, we first propose an adaptive anchoring region proposal network (AA-RPN) to generate proposals for diverse-scale fractures with low computational complexity. Then, based on the prior knowledge that cranial sutures exist in the junctions of bones and usually contain sclerotic margins, we design an anti-interference head (A-Head) network to eliminate the cranial suture interference for better SFD detection. In addition, to further enhance the anti-interference ability of the proposed A-Head, a difficulty-balanced weighted loss function is proposed to emphasize more on distinguishing the interference areas from the skull base and the cranial sutures during training.

RESULTS

Experimental results demonstrate that the proposed Fracture R-CNN outperforms the current state-of-the-art (SOTA) deep detectors for SFD with a higher recall and fewer false detections. Compared to Faster R-CNN, the proposed Fracture R-CNN improves the average precision (AP) by 11.74% and the free-response receiver operating characteristic (FROC) score by 11.08%. Through validating on various backbones, we further demonstrate the architecture independence of Fracture R-CNN, making it extendable to other detection applications.

CONCLUSIONS

As the customized deep learning-based framework for SFD, Fracture R-CNN can effectively overcome the unique challenges in SFD with less computational cost, leading to a better detection performance compared to the SOTA deep detectors. Moreover, we believe the prior knowledge explored for Fracture R-CNN would shed new light on future deep learning approaches for SFD.

Endoscopic endonasal approaches for reconstruction of traumatic anterior skull base fractures and associated cerebrospinal fistulas: patient series

BACKGROUND

Post-traumatic cerebrospinal fluid (CSF) leaks of the anterior skull base may arise after traumatic brain injury (TBI). Onset of CSF rhinorrhea may be delayed after TBI and without prompt treatment may result in debilitating consequences. Operative repair of CSF leaks caused by anterior skull base fractures may be performed via open craniotomy or endoscopic endonasal approaches (EEAs). The authors' objective was to review their institutional experience after EEA for repair of TBI-related anterior skull base defects and CSF leaks.

OBSERVATIONS

A retrospective review of prospectively collected data from a major level 1 trauma center was performed to identify patients with TBI who developed CSF rhinorrhea. Persistent or refractory post-traumatic CSF leaks and anterior skull base defects were repaired via EEA in four patients. Intrathecal fluorescein was administered before EEA in three patients (75%) to help aid identification of the fistula site(s). CSF leaks were eventually repaired in all patients, though one reoperation was required. During a mean follow-up of 8.75 months, there were no instances of recurrent CSF leakage.

LESSONS

Refractory, traumatic CSF leaks may be effectively repaired via EEA using a multilayer approach and nasoseptal flap reconstruction, thereby potentially obviating the need for additional craniotomy in the post-TBI setting.

Brainstem auditory evoked potential combined with high resolution cranial base CT can optimize the diagnosis of auditory nerve injury

PURPOSE

Auditory nerve injury is one of the most common nerve injury complications of skull base fractures. However, there is currently a lack of auxiliary examination methods for its direct diagnosis. The purpose of this study was to find a more efficient and accurate means of diagnosis for auditory nerve injury.

METHODS

Through retrospectively analyzing the results of brainstem auditory evoked potential (BAEP) and high-resolution CT (HRCT) in 37 patients with hearing impairment following trauma from January 1, 2018 to July 31, 2020, the role of the two inspection methods in the diagnosis of auditory nerve injury was studied. Inclusion criteria were patient had a clear history of trauma and unilateral hearing impairment after trauma; while exclusion criteria were: (1) severe patient with a Glasgow coma scale score ≤5 because these patients were classified as severe head injury and admitted to the intensive care unit, (2) patient in the subacute stage admitted 72 h after trauma, and (3) patient with prior hearing impairment before trauma. According to Goodman's classification of hearing impairment, the patients were divided into low/medium/severe injury groups. In addition, patients were divided into HRCT-positive and negative groups for further investigation with their BAEP results. The positive rates of BEAP for each group were observed, and the results were analyzed by Chi-square test (p < 0.05, regarded as statistical difference).

RESULTS

A total of 37 patients were included, including 21 males and 16 females. All of them were hospitalized patients with GCS score of 6-15 at the time of admission. The BAEP positive rate in the medium and severe injury group was 100%, which was significantly higher than that in the low injury group (27.27%) (p < 0.01). The rate of BEAP positivity was significantly higher in the HRCT-positive group (20/30, 66.7%) than in the HRCT-negative group (1/7, 14.3%) (p < 0.05). Twenty patients (54.05%) were both positive for BEAP and HRCT test, and considered to have auditory nerve damage. Six patients (16.22%) were both negative for BEAP and HRCT test, and 10 patients (27.03%) were BAEP-negative but HRCT-positive: all the 16 patients were considered as non-neurological injury. The rest 1 case (2.70%) was BAEP-positive but HRCT-negative, which we speculate may have auditory nerve concussion.

CONCLUSION

By way of BAEP combining with skull base HRCT, we may improve the accuracy of the diagnosis of auditory nerve injury. Such a diagnostic strategy may be beneficial to guiding treatment plans and evaluating prognosis.

A retrospective analysis of the skull base fractures: demographic characteristics, causes and imaging findings

Background and objectives: Skull base fractures have high mortality and morbidity rates and constitute a significant medical issue. The aim of the present study was to review the demographic characteristics, common locations and causes of the skull base fractures retrospectively. Methods: This retrospective study was conducted on patients who attended the Intensive Care Unit/Radiology Clinic of Adiyaman University Training and Research Hospital between 2015 and 2018 and were found to have skull base fractures. The data were accessed via PACS system of the hospital database. Age, gender, cause of the trauma, type of the skull base fracture, imaging findings and outcome of the enrolled patients were analyzed. Results: Total 138 cases who met the study criteria were enrolled in the study. The causes of the skull base fracture were as follows: fall 52.2%, traffic accident 36.2%, pounding 3.6%, firearm injury 0.7%, sharp object injury 0.7%, and other causes 6.5%. There was a statistically significant (p<0.001) difference in rate of skull base fracture caused by traffic accident between the ≤18-year group and 19-45 age group. The difference between the types of epidural hematoma was not significant in all age groups (p= 0.156); however, there was a statistically significant difference for gender (female vs. male 26.1%73.9%, p=0.025). Conclusion: Skull base fractures were more common in fall from height and traffic accidents. In order to reduce skull base fractures, it is recommended to take preventive precautions for falls from height and traffic accidents. IMC J Med Sci 2022; 16(2): 002. DOI:https://doi.org/10.55010/imcjms.16.012 *Correspondence: Safiye Kafadar, Department of Radiology, Adiyaman University Education and Research Hospital, Adiyaman, Turkey. Email: safiyekafadar@gmail.com, ORCID: 0000-0003-4070-9615

Association of frontal and maxillary bone fractures and concomitant craniocerebral injuries in patients presenting with head trauma

Background

Maxillofacial fractures and craniocerebral injuries are common in patients with head trauma. These are injuries with high mortality and morbidity. Therefore, patients with head trauma should be evaluated early with a multidisciplinary approach.

Aim

The association between frontal and maxillary bone fractures and concurrent craniocerebral injuries were investigated in patients presenting with head trauma in this study. The data of the patients were analyzed retrospectively.

Methods and Material

Age and gender distributions were evaluated in frontal and maxillary fractures. Concomitant craniocerebral injuries were investigated. Craniocerebral injuries were grouped as pneumocephalus, extra-axial, intra-axial injuries and brain edema. Craniocerebral injuries in frontal and maxillary fractures were compared statistically.

Results

Frontal bone and maxillary bone fractures were detected in 24% and 95% of the patients. Coexistence of pneumocephalus and intra-axial injuries in frontal bone fracture was statistically significant. The association of frontal posterior wall fractures with pneumocephalus and parenchymal contusion was found to be statistically significant. In addition, the association of craniocerebral injuries were evaluated and statistically significant ones were determined.

Conclusion

The presence of maxillofacial fractures in patients presenting with head trauma increases mortality and morbidity. Craniocerebral injuries can be life-threatening and delay the treatment of facial fractures. Upper facial bone fractures are significantly more common in craniocerebral injuries.

Primary Repair of Posteriorly Located Anterior Skull Base Dural Defects Using Nonpenetrating Titanium Clips in Cranial Trauma

Objective Primary repair of posteriorly located anterior skull base (ASB) dural defects following cranial trauma is made difficult by narrow operative corridors and adherent dura mater. Inadequate closure may result in continued cerebrospinal fluid (CSF) leak and infectious sequelae. Here, we report surgical outcomes following the use of nonpenetrating titanium microclips as an adjunctive repair technique in traumatic anterior skull base dural defects extending from the olfactory groove to the tuberculum sellae.

Methods All trauma patients who underwent a bifrontal craniotomy from January 2013 to October 2019 were retrospectively reviewed. Patients with ASB defects located at posterior to the olfactory groove were analyzed. Patients with isolated frontal sinus fractures were excluded. All patients presented with CSF leak or radiographic signs of dural compromise. Patients were divided according to posterior extent of injury. Patient characteristics, imaging, surgical technique, and outcomes are reported.

Results A total of 19 patients who underwent a bifrontal craniotomy for repair of posteriorly located ASB dural defects using nonpenetrating titanium microclips were included. Defects were divided by location: olfactory groove (10/19), planum sphenoidale (6/19), and tuberculum sellae (3/19). No patients demonstrated a postoperative CSF leak. No complications related to the microclip technique was observed. Clip artifact did not compromise postoperative imaging interpretation.

Conclusion Primary repair of posteriorly located ASB dural defects is challenging due to narrow working angles and thin dura mater. Use of nonpenetrating titanium microclips for primary repair of posteriorly located dural defects is a reasonable adjunctive repair technique and was associated with no postoperative CSF leaks in this cohort.

Dural Venous Sinus Thrombosis in Patients Presenting with Blunt Traumatic Brain Injuries and Skull Fractures: A Systematic Review and Meta-Analysis

BACKGROUND

Dural venous sinus thrombosis (DVST) is an increasingly recognized complication of blunt traumatic brain injury (TBI) and skull fractures. However, data concerning epidemiology and clinical significance of DVST are unclear. Determining the disease burden in patients with TBI is an important first step to guide future studies assessing the natural course of traumatic DVST or the effects of its treatment. Therefore, we performed to our knowledge the first systematic review and meta-analysis evaluating the prevalence of DVST in patients with TBI and skull fractures.

METHODS

MEDLINE and Embase databases were systematically searched for relevant studies published up to March 2018. All studies that assessed the prevalence of DVST among patients with TBI who underwent a vascular imaging study were included. The primary outcome was the presence or absence of DVST on imaging. A random-effects meta-analysis was used to pool studies.

RESULTS

Our systematic review yielded 638 articles, and 13 articles met inclusion criteria. In patients with skull fractures adjacent to a venous sinus, the prevalence was 26.2% (95% confidence interval = 19.4%-34.4%). This elevated risk was similar between adult (pooled estimate 23.8%; 95% CI = 16.2%-33.5%) and pediatric (pooled estimate 31.3%; 95% CI = 19.1%-46.9%) populations.

CONCLUSIONS

We found an unexpectedly high and consistent frequency of DVST among patients with skull fractures regardless of age group or severity of brain injury. These findings are important and highlight the need for further understanding the natural history of DVST and providing better guidelines on its management.

Influence of Skull Fracture on Traumatic Brain Injury Risk Induced by Blunt Impact

This study is aimed at investigating the influence of skull fractures on traumatic brain injury induced by blunt impact via numerous studies of head-ground impacts. First, finite element (FE) damage modeling was implemented in the skull of the Total HUman Model for Safety (THUMS), and the skull fracture prediction performance was validated against a head-ground impact experiment. Then, the original head model of the THUMS was assigned as the control model without skull element damage modeling. Eighteen (18) head-ground impact models were established using these two FE head models, with three head impact locations (frontal, parietal, and occipital regions) and three impact velocities (25, 35, and 45 km/h). The predicted maximum principal strain and cumulative strain damage measure of the brain tissue were employed to evaluate the effect of skull fracture on the cerebral contusion and diffuse brain injury risks, respectively. Simulation results showed that the skull fracture could reduce the risk of diffuse brain injury risk under medium and high velocities significantly, while it could increase the risk of brain contusion under high-impact velocity.

Risks, costs, and outcomes of cerebrospinal fluid leaks after pediatric skull fractures: a MarketScan analysis between 2007 and 2015

OBJECTIVE

Skull fractures are common after blunt pediatric head trauma. CSF leaks are a rare but serious complication of skull fractures; however, little evidence exists on the risk of developing a CSF leak following skull fracture in the pediatric population. In this epidemiological study, the authors investigated the risk factors of CSF leaks and their impact on pediatric skull fracture outcomes.

METHODS

The authors queried the MarketScan database (2007–2015), identifying pediatric patients (age < 18 years) with a diagnosis of skull fracture and CSF leak. Skull fractures were disaggregated by location (base, vault, facial) and severity (open, closed, multiple, concomitant cerebral or vascular injury). Descriptive statistics and hypothesis testing were used to compare baseline characteristics, complications, quality metrics, and costs.

RESULTS

The authors identified 13,861 pediatric patients admitted with a skull fracture, of whom 1.46% (n = 202) developed a CSF leak. Among patients with a skull fracture and a CSF leak, 118 (58.4%) presented with otorrhea and 84 (41.6%) presented with rhinorrhea. Patients who developed CSF leaks were older (10.4 years vs 8.7 years, p < 0.0001) and more commonly had skull base (n = 183) and multiple (n = 22) skull fractures (p < 0.05). These patients also more frequently underwent a neurosurgical intervention (24.8% vs 9.6%, p < 0.0001). Compared with the non–CSF leak population, patients with a CSF leak had longer average hospitalizations (9.6 days vs 3.7 days, p < 0.0001) and higher rates of neurological deficits (5.0% vs 0.7%, p < 0.0001; OR 7.0; 95% CI 3.6–13.6), meningitis (5.5% vs 0.3%, p < 0.0001; OR 22.4; 95% CI 11.2–44.9), nonroutine discharge (6.9% vs 2.5%, p < 0.0001; OR 2.9; 95% CI 1.7–5.0), and readmission (24.7% vs 8.5%, p < 0.0001; OR 3.4; 95% CI 2.5–4.7). Total costs at 90 days for patients with a CSF leak averaged $81,206, compared with $32,831 for patients without a CSF leak (p < 0.0001).

CONCLUSIONS

The authors found that CSF leaks occurred in 1.46% of pediatric patients with skull fractures and that skull fractures were associated with significantly increased rates of neurosurgical intervention and risks of meningitis, hospital readmission, and neurological deficits at 90 days. Pediatric patients with skull fractures also experienced longer average hospitalizations and greater healthcare costs at presentation and at 90 days.

Analysis and Clinical Importance of Skull Base Fractures in Adult Patients with Traumatic Brain Injury

Aims and Objectives:

Basal skull fracture (BSF) is rare in head injury (HI) patients and occasionally goes unnoticed which may lead to cerebrospinal fluid (CSF) fistula. With changing trends in HI, there is a need to reassess incidence and pattern of BSF pattern, CSF leak, meningitis, and management protocol, especially in this part of the world where detailed literature is lacking.

Subjects and Methods:

We closely followed adult patients admitted with BSF in our institute between January 2013 and December 2014. Associated clinical features were recorded. In case of CSF leak, detailed CSF study was done and patients were managed accordingly. Patients with persistent CSF leak were managed surgically.

Results:

During the study period, 194 of 5041 HI patients had evidence of BSF (3.85%). BSF was most commonly associated with moderate-to-severe HI (73.19%). About 81.44% patients were male and 29.9% were <30 years. Most common cause was road traffic accident (84.54%). Isolated anterior cranial fossa (ACF) fracture was most common (50%). About 63.92% patients had raccoon eyes. Forty-three patients had CSF leak with CSF rhinorrhea being more common. Culture of only 5 patients suggested bacterial meningitis. CSF leak lasted for more than 10 days in 8 patients, of which 4 patients required surgical repair.

Conclusions:

BSF is rare in victims of HI. It is more common in young adult males. ACF fractures are most common in our setup. Clinical signs of BSF are supportive but not definitive; high resolution computed tomography head is gold standard to detect BSF. CSF leak is rare and most of the cases can be managed conservatively. Leak persisting more than 7–10 days has high risk of developing meningitis and likely to need surgical intervention.

Pioglitazone Therapy and Fractures: Systematic Review and Meta- Analysis

INTRODUCTION

Thiazolidinediones are a group of synthetic medications used in type 2 diabetes treatment. Among available thiazolidinediones, pioglitazone is gaining increased attention due to its lower cardiovascular risk in type 2 diabetes mellitus sufferers and seems a promising future therapy. Accumulating evidence suggests that diabetic patients may exert bone fractures due to such treatments. Simultaneously, the female population is thought to be at greater risk. Still, the safety outcomes of pioglitazone treatment especially in terms of fractures are questionable and need to be clarified.

METHODS

We searched MEDLINE, Scopus, PsyInfo, eLIBRARY.ru electronic databases and clinical trial registries for studies reporting an association between pioglitazone and bone fractures in type 2 diabetes mellitus patients published before Feb 15, 2016. Among 1536 sources that were initially identified, six studies including 3172 patients proved relevant for further analysis.

RESULT

Pooled analysis of the included studies demonstrated that after treatment with pioglitazone patients with type 2 diabetes mellitus had no significant increase in fracture risk [odds ratio (OR): 1.18, 95% confidence interval (CI): 0.82 to 1.71, p=0.38] compared to other antidiabetic drugs or placebo. Additionally, no association was found between the risk of fractures and pioglitazone therapy duration. The gender of the patients involved was not relevant to the risk of fractures, too.

CONCLUSION

Pioglitazone treatment in diabetic patients does not increase the incidence of bone fractures. Moreover, there is no significant association between patients' fractures, their gender and the period of exposure to pioglitazone. Additional longitudinal studies need to be undertaken to obtain more detailed information on bone fragility and pioglitazone therapy.

Success Rate and Complications of Cerebrospinal Fluid Rhinorrhea Treated With a Transcranial Approach

The aim of this study was to evaluate the clinical outcomes of cerebrospinal fluid (CSF) rhinorrhea in patients treated with transcranial surgery. Here, we retrospectively reviewed 23 patients with CSF rhinorrhea between 2008 and 2015 at our university hospital. Nine (39.1%) patients were treated conservatively, whereas 12 (52.2%) patients were treated with a transcranial approach. Our results showed that 7 (30.4%), 11 (47.8%), and 5 (21.7%) patients had spontaneous, traumatic, and iatrogenic CSF leakage, respectively. In our study, the cribriform plate was the most common site of leakage, and it was found to be involved in 5 (21.7%) patients. The mean diameter defect of the fistula was 130.40 ± 190.47 mm and there was no significant difference between this defect and the different etiology types. In our study, meningitis, third nerve palsy, and vasospasm were the main complications that arose during the treatment of CSF rhinorrhea. Moreover, 6 (26.1%) of 7 (30.4%) patients had spontaneous CSF leaks that were treated with surgery. Notably, spontaneous CSF leaks did not stop when treated with conservative measures. In addition, there were no significant differences between etiology types and CSF leaks. The primary surgical repair rate was 78.3% and the secondary surgery repair rate was 91.6%. Importantly, as we preferred using this type of transcranial surgery in our clinic, there has been a higher success rate with endoscopic treatments and fewer major complications from CSF rhinorrhea in the literature.

Clinical Signs of Basilar Skull Fracture and Their Predictive Value in Diagnosis of This Injury

Although clinical signs for the diagnosis of basilar skull fracture (BSF) are ambiguous, they are widely used to make decisions on initial interventions involving trauma patients. We aimed to assess the performance of early and late (within 48 hr posttrauma) signs for BSF diagnosis and to verify the correlation between the presence of these signs and head injury severity. We conducted a prospectively designed follow-up study at a referral hospital for trauma care in Sao Paulo, Brazil, and performed structured observations for 48 hr post-blunt head injury in patients aged 12 years or older. The following signs of BSF were considered: raccoon eyes, Battle's sign, otorrhea, and rhinorrhea. Among the 136 enrolled patients (85.3% male; mean age 40 ± 21.4 years), 28 patients (20.6%) had BSF. The clinical signs for the early or late detection of BSF had low accuracy (55.9% vs. 43.4%), specificity (52.8% vs. 30.5%), and positive predictive value (25.7% vs. 27.1%). However, the presence of these signs was correlated to head injury severity, indicated by the Glasgow Coma Scale (p = .041) and Maximum Abbreviated Injury Scale-Head region (p = .002). In view of the low accuracy of these signs, resulting low clinical value of their presence, and their high sensitivity in the late stage, the study results contraindicate the value of BSF signs for making decisions about using the nasal route for the introduction of catheters and tubes in initial trauma care.

Number of Fractured Calvarial Bones Predicts Outcome in Traumatic Brain Injury Patients After Early Craniotomy

BACKGROUND

Prognostic markers are important for neurosurgeons to evaluate the indications for aggressive surgical management. The purpose of this study was to investigate whether the number of fractured calvarial bones could predict the outcome in patients with traumatic brain injury (TBI) after early craniotomy.

METHODS

TBI patients who underwent early craniotomy were reviewed. The number of fractured calvarial bones was recorded by referring to preoperative computed tomographic (CT) images. Accordingly, patients were assigned to no calvarial fracture group, single calvarial fracture group, and multiple calvarial fractures group. Good outcome was defined as Glasgow Outcome Scale scores of 4 and 5 at discharge. Logistic regression analyses were used to assess the effect of calvarial fracture on outcome. A receiver operating characteristic curve was generated for the final model.

RESULTS

In all, a total of 141 patients were enrolled. Patients with no calvarial fracture had a significantly lower rate of good outcome (12.5%) than did those with a single calvarial fracture (62.2%, P < 0.001) and those with multiple calvarial fractures (48.6%, P = 0.005). Binary logistic regression showed that the number of fractured calvarial bones was an independent imaging marker for predicting outcome (P = 0.003) after adjustment for age, Glasgow Coma Scale score on admission, and decompressive craniectomy. The area under the curve of the final model was 0.863.

CONCLUSIONS

The number of fractured calvarial bones is an independent predictor of outcome in TBI patients after early craniotomy. No calvarial facture is associated with poor outcome in these patients.

Clinical Significance of Long-Term Follow-Up of Children with Posttraumatic Skull Base Fracture

OBJECTIVE

To assess the incidence of cerebrospinal fluid (CSF) leak and meningitis, and the need for prophylactic antibiotics, antipneumococcal vaccination, and surgical interventions, in children with a skull base fracture.

METHODS

We reviewed the records of children with a skull base fracture who were admitted to our tertiary care center between 2009 and 2014.

RESULTS

A total of 196 children (153 males), age 1 month to 18 years (mean age, 6 ± 4 years), were hospitalized with skull base fracture. Causes of injury were falls (n = 143), motor vehicle accidents (n = 34), and other (n = 19). Fracture locations were the middle skull base in 112 patients, frontal base in 62, and occipital base in 13. Fifty-four children (28%) had a CSF leak. In 34 of these children (63%), spontaneous resolution occurred within 3 days. Three children underwent surgery on admission owing to a CSF leak from an open wound, 3 underwent CSF diversion by spinal drainage, and 4 (2%) required surgery to repair a dural tear after failure of continuous spinal drainage and acetazolamide treatment. Twenty-eight children (14%) received prophylactic antibiotic therapy, usually due to other injuries, and 11 received pneumococcal vaccination. Two children developed meningitis, and 3 children died. Long-term follow up in 124 children revealed 12 children with delayed hearing loss and 3 with delayed facial paralysis.

CONCLUSIONS

This is the largest pediatric series of skull base fractures reporting rates of morbidity and long-term outcomes published to date. The rate of meningitis following skull base fracture in children is low, supporting a policy of not administering prophylactic antibiotics or pneumococcal vaccine. Long-term follow up is important to identify delayed complications.

Brain contusion as the main risk factor of memory or emotional complaints in chronic complicated mild traumatic brain injury

OBJECTIVE

To investigate the risk factors for memory or emotional complaints in patients with complicated mild traumatic brain injury (mTBI).

METHODS

Retrospective analysis of medical records was conducted by physicians in a teaching hospital in Southern Taiwan, and complicated mTBI had been identified by means of computed tomography. Psychological complaints, including problems with memory and emotions, were collected by structured telephone interviews, 10-15 minutes long, and were held with subjects who agreed to participate in our study. Among 327 patients who were injured for more than two years, 190 agreed to join this study (mean age: 41.6 years; male: 60.5%; stably employed: 50.0%). We used demographic data and neurological factors to predict memory or emotional complaints without muscle power or response speed (MEMR) complaints.

RESULTS

Only the presence or absence of cerebral contusions predicted memory or emotional complaints without MEMR complaints in different employed status, and the odds ratio was 4.82-13.50 times higher for those with cerebral contusions than for those without.

CONCLUSIONS

Cerebral contusions were the primary risk factor for MEMR complaints in chronic complicated mTBI. Early preventive psychological intervention might be necessary for patients with complicated mTBI and cerebral contusions.