Traumatic cerebrospinal fluid leaks

Imaging Findings in Acute Traumatic Brain Injury: a National Institute of Neurological Disorders and Stroke Common Data Element-Based Pictorial Review and Analysis of Over 4000 Admission Brain Computed Tomography Scans from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study

In 2010, the National Institute of Neurological Disorders and Stroke (NINDS) created a set of common data elements (CDEs) to help standardize the assessment and reporting of imaging findings in traumatic brain injury (TBI). However, as opposed to other standardized radiology reporting systems, a visual overview and data to support the proposed standardized lexicon are lacking. We used over 4000 admission computed tomography (CT) scans of patients with TBI from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study to develop an extensive pictorial overview of the NINDS TBI CDEs, with visual examples and background information on individual pathoanatomical lesion types, up to the level of supplemental and emerging information (e.g., location and estimated volumes). We documented the frequency of lesion occurrence, aiming to quantify the relative importance of different CDEs for characterizing TBI, and performed a critical appraisal of our experience with the intent to inform updating of the CDEs. In addition, we investigated the co-occurrence and clustering of lesion types and the distribution of six CT classification systems. The median age of the 4087 patients in our dataset was 50 years (interquartile range, 29-66; range, 0-96), including 238 patients under 18 years old (5.8%). Traumatic subarachnoid hemorrhage (45.3%), skull fractures (37.4%), contusions (31.3%), and acute subdural hematoma (28.9%) were the most frequently occurring CT findings in acute TBI. The ranking of these lesions was the same in patients with mild TBI (baseline Glasgow Coma Scale [GCS] score 13-15) compared with those with moderate-severe TBI (baseline GCS score 3-12), but the frequency of occurrence was up to three times higher in moderate-severe TBI. In most TBI patients with CT abnormalities, there was co-occurrence and clustering of different lesion types, with significant differences between mild and moderate-severe TBI patients. More specifically, lesion patterns were more complex in moderate-severe TBI patients, with more co-existing lesions and more frequent signs of mass effect. These patients also had higher and more heterogeneous CT score distributions, associated with worse predicted outcomes. The critical appraisal of the NINDS CDEs was highly positive, but revealed that full assessment can be time consuming, that some CDEs had very low frequencies, and identified a few redundancies and ambiguity in some definitions. Whilst primarily developed for research, implementation of CDE templates for use in clinical practice is advocated, but this will require development of an abbreviated version. In conclusion, with this study, we provide an educational resource for clinicians and researchers to help assess, characterize, and report the vast and complex spectrum of imaging findings in patients with TBI. Our data provides a comprehensive overview of the contemporary landscape of TBI imaging pathology in Europe, and the findings can serve as empirical evidence for updating the current NINDS radiologic CDEs to version 3.0.

Favorable effects of open surgery on patients with extensive skull base osteoradionecrosis through a personalized sequential approach: A case series

The present study aimed to investigate outcomes following open surgery for extensive skull base ORN. Open surgery through a personalized sequential approach was employed to deal with five cases of extensive skull base ORN. Two patients with mild cases underwent regional debridement and sequestrectomy, and three patients with severe cases underwent extensive resection with reconstruction using free anterolateral thigh (ALT) flap. Biological glues and vascularized flaps were used for obturation of the skull base bony defect to prevent postoperative cerebrospinal fluid (CSF) leakage. The infections were controlled by antibiotic administrations which strictly followed the principles of antimicrobial stewardship (AMS). As results, both regional debridement plus sequestrectomy and extensive resection achieved satisfied outcomes in all patients. No severe complications and delayed hospitalization occurred. During the follow-up period (8-19 months), all patients were alive, pain free, without crusting or purulent discharge, and no sequestration or CSF leakage occurred. In conclusion, a personalized sequential approach including open surgery, pedicled/vascularized free flap reconstruction and AMS was advocated for patients with extensive skull base ORN.

"Sealing the Gap" : CSF Leakage Demystified-A Comprehensive Analysis of our Experience in CSF Rhinorrhea Management

CSF (Cerebro Spinal Fluid) rhinorrhoea occurs when the fluid leaks from subarachnoid space into the nasal cavity. The study aims to find out the prevalence and demographic distribution of CSF leak and to describe the site of the CSF leak along with the management. We did a prospective study on 180 patients admitted with head injury in neurosurgery department, along with the patients who came to ENT department with unilateral nasal discharge during the time period from March 2017 to March 2021. A total of 36 cases of CSF leak were obtained during the time period. The etiology in 18 cases was head injury & the other 18 cases were either due to infectious or nontraumatic causes. In our study, 26(72.22%) patients were aged less than 50 years. Incidence was more among males compared to females. The most common etiology was head injury - 18(50%) patients followed by the spontaneous leak- 16 (44.44%) patients with the most common site as the cribriform plate. Endoscopic repair using a hadad flap was done in most of the patients. Trauma due to head injury is the most common etiology in CSF rhinorrhea with more number of patients aged less than 50 years. Most of the leaks can be repaired successfully with the use of endoscope with excellent illumination & localizing the exact site of the leak.

The Examination of Prognostic Factors and Treatment Strategies for Traumatic Cerebrospinal Fluid Leakage

Introduction This study aimed to determine the optimal timing for surgical intervention and the prognostic factors of cerebrospinal fluid (CSF) leakage. Methods We identified 25 patients with probable CSF leaks from 472 consecutive patients with head trauma. In addition to baseline characteristics and findings on admission, injury severity score (ISS), abbreviated injury score (AIS), and other factors related to CSF leakage were considered. We analyzed the prognostic factors after setting the primary endpoint as the modified Rankin Scale (mRS) at the time of discharge to determine the appropriate timing for surgical intervention. Results Univariate analysis revealed significantly poorer prognoses for elderly patients (p<0.001) and cases with low Glasgow Coma Scale (GCS) levels (p=0.039) and high D-dimer levels (p=0.028), which was consistent with findings from the analyses of all patients with head trauma. We found that multiple traumas (AIS≥3 at two or more sites, p=0.047) and high lactate levels (p=0.043) were poor prognostic factors specific to CSF leakage cases, while a longer time to CSF leakage cessation was also associated with a poorer prognosis (median, six days versus 13 days, p=0.014). An evaluation of the time to closure found that spontaneous cessation occurred within 14 days in most cases. Conclusions Conservative medical treatment is the first choice for most cases of traumatic CSF leakage. Surgical intervention should be considered if leakage does not cease after 14 days post injury. Furthermore, severe multiple injuries and high lactate levels were poor prognostic factors specific to patients with CSF leakage.

Endoscopic Endonasal Repair and Reconstruction of Traumatic Anterior Skull Base Defects

Eighty percent of cerebrospinal fluid leaks (CSF) occur following trauma and complicate 12 to 13% percent of all basilar skull fractures (Prosser, Vender, and Solares, 2011). An endoscopic endonasal approach (EEA) is often the preferred method of repair with greater than 90% success rates (Prosser, Vender, and Solares, 2011). We report a case of a 37-year-old man who presented to our regional level 1 trauma centre with multiple facial injuries. Initial cross-sectional imaging revealed multiple, continuous anterior skull base fractures with associated pneumocephalus. Though initially managed conservatively, the patient represented five days later with unilateral left-sided rhinorrhoea. An endoscopic endonasal repair with a multilayer fat, tensor fascia lata, free mucosal graft, and vascularised local flap reconstruction was undertaken. This case highlights the importance of maintaining a high level of suspicion for delayed CSF leak in traumatic base of skull injury. The EEA enables meticulous dissection and thorough inspection of the skull base, facilitating multilayered repair and reconstruction of defects.

Cut-off value for β-trace protein (β-TP) as a rapid diagnostic of cerebrospinal fluid (CSF) leak detection

Objective

To find an adequate cut-off point for beta trace protein (β-TP) in nasal secretion (NS) and validate this diagnostic test with a large sample of patients. Likewise, we evaluated β-TP test efficacy to confirm the cerebrospinal fluid (CSF) leakage closure after treatment.

Methods

We performed a retrospective analysis with 207 samples from 162 patients with suspected CSF leakage received in the Hospital Universitario Virgen de la Arrixaca between 2010 and 2016. Twenty-five samples were included in the control group. Samples were obtained from NS through a swab to determine β-TP using a nephelometry-based assay. Sensitivity, specificity, and area under the curve (AUC) for β-TP in NS were assessed using the receiver operator characteristic (ROC) analysis.

Results

Using imaging techniques, the diagnosis of CSF leak was confirmed in 57 patients (35.19%), while 105 had a negative diagnosis (64.81%). Patients with CSF leakage had significantly higher β-TP values in NS (16.07 ± 16.94 mg/L, p < .001) than the control group (0.33 ± 0.12 mg/L) and patients without CSF leakage (0.61 ± 2.34 mg/L). Applying a 1 mg/L cut-off point resulted in 96.5% sensitivity and 97.1% specificity. Positive and negative predictive values (PPV and NPV) at this cut-off were 94.9% and 98.6%, respectively. Finally, this cut-off point yields a test efficacy for CSF leak diagnosis of 97% (95% CI 92.9-98.9).

Conclusion

Our study has established a 1 mg/L β-TP concentration in NS as a cut-off point for CSF leakage diagnosis with high sensibility and specificity. These results suggest that β-TP analysis could be useful to check CSF leak resolution.

Level of Evidence

4.

Small spheno-ethmoidal meningoencephalocele versus ethmoidal mucocele in spontaneous intracranial hypotension

Background

Meningoencephalocele is defined as an abnormal sac of brain tissue and meninges extending beyond natural skull margins, often leading to cerebrospinal fluid (CSF) leakage. When this condition arises in the spheno-ethmoidal region, the diagnosis becomes more challenging as it can be mistaken for other nasal pathologies, such as mucocele.

Research question

We show in this case report a non-congenital sphenoethmoidal meningoencephalocele causing rhinoliquoral fistula and spontaneous intracranial hypotension.

Results

this 65-year-old woman presented with sporadic rhinoliquorrhoea associated with orthostatic headache, nausea and dizziness. Brain MRI revealed a small lesion of an ethmoidal sinus, which was successfully treated with endoscopic endonasal surgery. Histology confirmed the presence of meningoencephalic tissue positive for S100 protein on immunohistochemistry.

Conclusions

When dealing with lesions of the paranasal sinuses in contact with the anterior skull base, rhinoliquorrhoea presence suggests meningoencephalocele. In dubious cases, a proper workup, including a thorough clinical history and neurological examination, specific imaging, and a direct search of CSF-like markers, is essential to support the differential diagnosis. In such cases, a transnasal endoscopic surgical approach is recommended to obtain a final histological diagnosis and to perform eventual dural plastic surgery.

Case report: Post-traumatic Tourette syndrome resolving with treatment of jugular venous narrowing; reconciling organic brain dysfunction following whiplash trauma with the absence of direct brain injury

We describe a man aged 33 years who developed multiple symptoms, personality change, and a severe tic disorder following a road traffic accident, which were undiminished for 3 years until jugular venous narrowing between the styloid process of the skull and the transverse process of the C1 vertebra was treated by surgical decompression. Immediately following surgery, his abnormal movements almost completely resolved, with no regression in 5 years of follow-up. Vigorously debated at the time was whether or not his condition represented a functional disorder. Unrecognized throughout his illness, however, was a complaint of intermittent, profuse discharge of clear fluid from his nose that began on the day of the accident and continued up to the time of surgery, after which it was substantially reduced. This outcome reinforces the idea that jugular venous narrowing can cause or perpetuate a cerebrospinal fluid leak. It suggests that the interaction between these two pathological defects may have a profound effect on brain function in the absence of any demonstrable brain lesion. It invites a reevaluation of normal head and neck venous anatomy. It should strike a cautionary note in the diagnosis of functional illness. It invites exploration of a remediable structural cause for Tourette syndrome.

Review: Emerging Eye-Based Diagnostic Technologies for Traumatic Brain Injury

The study of ocular manifestations of neurodegenerative disorders, Oculomics, is a growing field of investigation for early diagnostics, enabling structural and chemical biomarkers to be monitored overtime to predict prognosis. Traumatic brain injury (TBI) triggers a cascade of events harmful to the brain, which can lead to neurodegeneration. TBI, termed the "silent epidemic" is becoming a leading cause of death and disability worldwide. There is currently no effective diagnostic tool for TBI, and yet, early-intervention is known to considerably shorten hospital stays, improve outcomes, fasten neurological recovery and lower mortality rates, highlighting the unmet need for techniques capable of rapid and accurate point-of-care diagnostics, implemented in the earliest stages. This review focuses on the latest advances in the main neuropathophysiological responses and the achievements and shortfalls of TBI diagnostic methods. Validated and emerging TBI-indicative biomarkers are outlined and linked to ocular neuro-disorders. Methods detecting structural and chemical ocular responses to TBI are categorised along with prospective chemical and physical sensing techniques. Particular attention is drawn to the potential of Raman spectroscopy as a non-invasive sensing of neurological molecular signatures in the ocular projections of the brain, laying the platform for the first tangible path towards alternative point-of-care diagnostic technologies for TBI.

Management of Traumatic and Non-Traumatic Cerebrospinal Fluid Rhinorrhea-Experience from Three Southeast Asian Countries

BACKGROUND

Cerebrospinal fluid (CSF) rhinorrhea requires proper management to avoid disastrous consequences. The objectives of this study were to ascertain the patient characteristics, etiologies, sites of defect, skull base configurations, methods of investigation, and management outcomes of CSF rhinorrhea.

METHODS

A retrospective study was performed over 4 years involving three surgeons from Malaysia, Singapore, and Thailand. Hospital records were reviewed to determine the patients' characteristics, the causes and sites of leaks, methods of investigation, skull base configurations, choices of treatment, and outcomes.

RESULTS

A total of 15 cases (7 traumatic and 8 non-traumatic) were included. Imaging was performed in all cases. The most common site of leakage was the cribriform plate (9/15 cases). The mean ± SD of the Keros heights were 4.43 ± 1.66 (right) and 4.21 ± 1.76 mm (left). Type II Keros was the most common (60%). The mean ± SD angles of the cribriform plate slope were 51.91 ± 13.43 degrees (right) and 63.54 ± 12.64 degrees (left). A class II Gera configuration was the most common (80%). All except two patients were treated with endonasal endoscopic surgical repair, with a success rate of 92.3%. A multilayered repair technique was used in all patients except one. The mean ± SD postoperative hospital stay was 9.07 ± 6.17 days.

CONCLUSIONS

Non-traumatic CSF rhinorrhea outnumbered traumatic CSF rhinorrhea, with the most common site of leak at the cribriform plate. Imaging plays an important role in investigation, and Gera classification appears to be better than Keros classification for evaluating risk. Both conservative and surgical repairs are practiced with successful outcomes. Endonasal endoscopic CSF leak repair is the mainstay treatment.

Approach to Management of Cerebrospinal Fluid Rhinorrhea: Institutional Based Protocol

The role of otolaryngologist in the management of CSF rhinorrhea is expanding. It is prudent to evaluate all cases of CSF leak, understand the etiological causes and formalize a working approach to management of such cases to yield better outcome. A retrospective descriptive study of 39 cases of proven CSF rhinorrhea treated at a tertiary care center between January 2014 to August 2019. The data retrieved were analyzed for age, gender, weight, etiology, recurrence of the disease, history of meningitis, nasal or neurosurgical intervention in past, imaging inform of CT and MR cisternography as and when required. This was aimed at understanding the various etiological types of CSF rhinorrhea and work out a management approach. The patients with skullbase tumors who presented with CSF Rhinorrhea were excluded from the study sample. There were 18 cases of spontaneous CSF rhinorrhea and 20 cases of traumatic CSF rhinorrhea. The mean BMI of spontaneous gp was 32.9 ± 2.46 kg/m2 while in traumatic group was 25.7 ± 2.94 kg/m2 and difference was statistically significant. None of the spontaneous CSF rhinorrhea cases showed features of raised ICP preoperatively either clinically or on imaging except empty sella in 14 of 18 cases. 6 of 18 cases of spontaneous category while 01 of 20 cases in traumatic had recurrence and the recurrence rate was significantly (p < 0.05) higher in spontaneous group. In traumatic group 7 were iatrogenic, 8 were occult traumatic and rest were acute traumatic. 4 of traumatic and 1 spontaneous group had history of meningitis and the incidence was 12.8% in our study group. Early identification and localization of CSF fistula is necessary to reduce morbidity and mortality associated with it. Risk of meningitis is high in CSF rhinorrhea especially in traumatic group. The etiology of CSF rhinorrhea has a bearing on the management and spontaneous CSF rhinorrhea has higher rate of recurrence.

Clinical risk factors associated with cerebrospinal fluid leak in facial trauma: A retrospective analysis

OBJECTIVE

Cerebrospinal fluid (CSF) leak occurs most commonly following skull fracture, with a CSF leakage complicating up to 2% of all head traumas. This study aims to identify demographic and injury characteristics correlated with the highest risk of CSF leak in patients with known facial fractures.

METHODS

Retrospective data was collected from a previously described trauma registry from 2010 to 2019. Patients over 18 years old with any type of facial fracture, known CSF leak status, available neuroimaging, and hospital admission were included. Chi-Square analysis for demographic and injury characteristic data were utilized.

RESULTS

A total of 79 patients with CSF leak and 4907 patients without CSF leak were included in the database. Patients with CSF leak tended to be younger than those without CSF leak (38.45 +/- 0.28 vs 44.08 +/- 0.28, M +/- SE, p = 0.0197). CSF leak depended on the mechanism of injury (MOI; X² =27.02, df=2, p = 0.0000013), with CSF leak rates highest in penetrating injuries (4.87%) and motor vehicle accidents (1.78%) compared to blunt injuries (0.95%); age did not significantly differ between the MOI groups (p = 0.11). CSF leak was also more common in patients with a lower Glasgow coma scale (GCS; 7.95 +/- 0.58 vs 12.21 +/- 0.10, p = 10^-15), LeFort type 2&3 and pan-facial fractures compared to all other facial fracture types (8.9% vs 1.2%, p = 10^-15), and radiographic midline shift (29.4% vs 9.1%, p = 10^-15). There was a trend towards a higher proportion of males in those with CSF leak compared to those without (83.3% vs 73.7% males, p = 0.073), and in patients with prolonged loss of consciousness (LOC; 9.43% with LOC > 1 h vs 2.69% LOC < 1 h, p = 0.056).

CONCLUSION

Facial fractures often present with CSF leak, and certain demographic and injury risk factors including younger age, worse GCS score, evidence of midline shift, and certain mechanisms of injury (penetrating and motor vehicle) are correlated with increased risk and warrant close screening and follow-up for CSF leak detection. LeFort type 2&3 and pan-facial fractures are at high risk of CSF leak.

Surgical Repair of Skull Base CSF Leaks after Cisternography Diagnosis: Analysis of Validity and Surgical Outcome and Impact on Future Treatment Strategies

Skull base cerebrospinal fluid (CSF) leaks can lead to severe complications and require appropriate diagnosis and treatment. Cisternography is applied when exact localization via conventional imaging is not successful. The present study is aimed at identifying factors with potential impact on radiological results and surgical success. Cisternography followed by surgical repair due to skull base CSF leaks was performed in 63 cases between 2002 and 2020. The clinical and radiological findings were analyzed retrospectively. The etiology of CSF leaks was traumatic in 30.2%, spontaneous in 36.5%, and iatrogenic in 33.3%. The sensitivity of cisternography was 87.9%. Spontaneous CSF leaks tended to be diagnosed less frequently via cisternography and were significantly less frequently localized intraoperatively. The median postoperative follow-up period was 34 months. The primary surgical success rate was 79.4%, with a significantly higher success rate for lateral than for anterior skull base defects. Surgical failure tended to be lower in iatrogenic and higher in traumatic defects. Cisternography proved to be a highly sensitive method to localize skull base CSF leaks and can be recommended for advanced diagnostics. Iatrogenic leaks seemed to be more likely to have a favorable surgical outcome, whereas traumatic leaks tended to have a lower surgical success rate.

Cerebrospinal fluid leak management in anterior basal skull fractures secondary to head trauma

OBJECTIVE

To summarize the presentation, diagnosis, and management of cerebrospinal fluid (CSF) leaks in the setting of traumatic anterior skull base fracture.

METHODS

Wide literature research has been performed as well as the authors' own clinical experience has been summarized.

RESULTS

Articles from the most recent 30 years have been reviewed and a typical case of our own has been presented. Based on the most updated evidence, a treatment algorithm for CSF leaks has been proposed.

CONCLUSION

Anterior skull base fracture accounts for about 4% of all head injuries and CSF leaks is a complication that commonly presents with clear fluid emanating from the nasal passage. A positive beta-2-transferrin study is highly specific for diagnosis, while thin-slice CT scanning and MRI cisternography are also useful tools. The majority of the CSF leaks tend to be resolved spontaneously, and conservative management is attempted first with or without the augmentation of a lumbar drain. Surgical management mainly includes open surgery and endoscopic surgery, which have their own pros and cons.

Cerebrospinal Fluid-philic and Biocompatibility-Enhanced Soft Cranial Window for Long-Term In Vivo Brain Imaging

Soft, transparent poly(dimethyl siloxane) (PDMS)-based cranial windows in animal models have created many opportunities to investigate brain functions with multiple in vivo imaging modalities. However, due to the hydrophobic nature of PDMS, the wettability by cerebrospinal fluid (CSF) is poor, which may cause air bubble trapping beneath the window during implantation surgery, and favorable heterogeneous bubble nucleation at the interface between hydrophobic PDMS and CSF. This may result in excessive growth of the entrapped bubble under the soft cranial window. Herein, to yield biocompatibility-enhanced, trapped bubble-minimized, and soft cranial windows, this report introduces a CSF-philic PDMS window coated with hydroxyl-enriched poly(vinyl alcohol) (PVA) for long-term in vivo imaging. The PVA-coated PDMS (PVA/PDMS) film exhibits a low contact angle θ_ACA (33.7 ± 1.9°) with artificial CSF solution and maintains sustained CSF-philicity. The presence of the PVA layer achieves air bubble-free implantation of the soft cranial window, as well as induces the formation of a thin wetting film that shows anti-biofouling performance through abundant water molecules on the surface, leading to long-term optical clarity. In vivo studies on the mice cortex verify that the soft and CSF-philic features of the PVA/PDMS film provide minimal damage to neuronal tissues and attenuate immune response. These advantages of the PVA/PDMS window are strongly correlated with the enhancement of cortical hemodynamic changes and the local field potential recorded through the PVA/PDMS film, respectively. This collection of results demonstrates the potential for future microfluidic platforms for minimally invasive CSF extraction utilizing a CSF-philic fluidic passage.

A brief report: Cerebrospinal fluid rhinorrhea after repetitive nasal swab testing for coronavirus disease 2019(COVID-19)

For the past year, COVID-19 Pandemic has been the biggest focal point of medicine. Due to its novelty and its highly infectious nature, the impact of Sars-Cov-2 on society has been growing rapidly. The primary route for prevention of this highly infectious virus is detection. The detection methods for Sars-Cov-2 include nasal swab tests, saliva samplings and antibody tests. The main preferred method has been the RT-PCR with Nasal Swab sampling which is performed on the nasopharyngeal region. However, the nasal swab testing may come with its own iatrogenic outcomes due to its invasiveness. In this report, we describe a rare case of iatrogenic unilateral cerebrospinal fluid rhinorrhea which occurred due to repetitive nasal swab testing for COVID-19.

Complications of Chest Wall Resection in Conjunction with Pulmonary Resection

Techniques for chest wall resection and reconstruction have evolved over the years. Chest wall resection in conjunction with pulmonary resection has several complications, including pulmonary and infectious. Risk factors for complications are related to the size of the defect, number of ribs resected, and the addition of a pulmonary resection. Material used for reconstruction does not impact the overall complication rate.

Characteristics of Pediatric Recurrent Bacterial Meningitis in Beijing Children's Hospital, 2006-2019

BACKGROUND

Few data on recurrent bacterial meningitis (RBM) in children are available. Here, we estimated the frequency of RBM in children and investigated the predisposing conditions, etiology, and clinical characteristics of RBM in children.

METHODS

Cases of RBM in the Beijing Children's Hospital medical record database between January 2006 and December 2019 were collected.

RESULTS

In total, 1905 children with bacterial meningitis (BM) were documented in the Beijing Children's Hospital medical record database. A total of 43 patients had RBM. The rate of RBM in children was 2.3% (43/1905). Forty (93.0%) patients had predisposing conditions, including 15 (34.9%) cases of inner ear malformations, 5 (11.6%) cases of dermal sinus tracts, 9 (20.9%) cases of head injury, 5 (11.6%) cases of congenital cranial meningocele, 3 (7.0%) cases of congenital skull base defects, 3 (7.0%) cases of immunodeficiency, and other 3 (7.0%) cases of unknown reason. Among all the 121 BM episodes, a total of 64 episodes were etiologically confirmed BM and the other 57 episodes were probable BM. Streptococcus pneumoniae (n = 52) was accounted for 81.3% of confirmed BM episodes. Thirty-four of the 37 patients with congenital or acquired anatomical defects were available to follow up after surgeries, and all of them had no BM after surgeries. Three patients with antibody deficiencies got intravenous immunoglobulin therapy and they did not suffer BM anymore.

CONCLUSIONS

RBM is rare in children. The majority of children with RBM had predisposing conditions including congenital/acquired anatomical defects and immunodeficiency. Interventions should be implemented to solve the underlying conditions to avoid RBM.

Blunt and Penetrating Severe Traumatic Brain Injury

Severe traumatic brain injury is a common problem. Current practices focus on the importance of early resuscitation, transfer to high-volume centers, and provider expertise across multiple specialties. In the emergency department, patients should receive urgent intracranial imaging and consideration for tranexamic acid. Close observation in the intensive care unit environment helps identify problems, such as seizure, intracranial pressure crisis, and injury progression. In addition to traditional neurologic examination, patients benefit from use of intracranial monitors. Monitors gather physiologic data on intracranial and cerebral perfusion pressures to help guide therapy. Brain tissue oxygenation monitoring and cerebromicrodialysis show promise in studies.

The association of Le Fort midfacial fractures with frontobasal injuries: a 17-year review of 125 cases, reflections on biomechanics, classifications and treatment

The frequency of midface and frontobasal fractures has increased over the past 40 years despite the improvement and stringent regulation implemented on modern safety equipment (belts, helmets…). This observation might be correlated with the progress of radiodiagnosis tools. Literature was reviewed according to Prisma guidelines. We searched for reviewed articles, published between January 2000 and December 2017, through Medline (Pubmed) online databases and ScienceDirect, using the following MeSH Keywords: "Le Fort classification", "Le Fort fracture", "Frontobasal fracture", "skull base fracture", "Midface Fractures". Among 652 patients with frontobasal fractures, 125 (19.1%) were associated with a Le Fort fracture. 59 (9%) were associated with Le Fort III fracture, 51 (7.8%) with Le Fort II fracture and 15 (2.3%) with Le Fort I fracture. When frontobasal fractures were associated with midfacial fractures, we found 18 cerebrospinal fluid leaks (11.8 %) and 19 cases of meningitis (12.5 %). When only the frontobasal area was involved, there were 6 cerebrospinal fluid leaks (4.3 %) and 6 meningitis (4.3 %). Our results highlight a regular association between Le Fort fractures and frontobasal fractures for stages II and stage III of Le Fort fractures and also found a higher rate of neuro-septic complication. Further research shall investigate treatment and monitoring recommendations fitting modern epidemiology of craniofacial traumatology.

Post-Traumatic Meningitis Is a Diagnostic Challenging Time: A Systematic Review Focusing on Clinical and Pathological Features

Post-traumatic meningitis is a dreadful condition that presents additional challenges, in terms of both diagnosis and management, when compared with community-acquired cases. Post-traumatic meningitis refers to a meningeal infection causally related to a cranio-cerebral trauma, regardless of temporal proximity. The PICO (participants, intervention, control, and outcomes) question was as follows: "Is there an association between traumatic brain injury and post-traumatic meningitis?" The present systematic review was carried out according to the Preferred Reporting Items for Systematic Review (PRISMA) standards. Studies examining post-traumatic meningitis, paying particular attention to victims of traumatic brain injury, were included. Post-traumatic meningitis represents a high mortality disease. Diagnosis may be difficult both because clinical signs are nonspecific and blurred and because of the lack of pathognomonic laboratory markers. Moreover, these markers increase with a rather long latency, thus not allowing a prompt diagnosis, which could improve patients' outcome. Among all the detectable clinical signs, the appearance of cranial cerebrospinal fluid (CSF) leakage (manifesting as rhinorrhea or otorrhea) should always arouse suspicion of meningitis. On one hand, microbiological exams on cerebrospinal fluid (CSF), which represent the gold standard for the diagnosis, require days to get reliable results. On the other hand, radiological exams, especially CT of the brain, could represent an alternative for early diagnosis. An update on these issues is certainly of interest to focus on possible predictors of survival and useful tools for prompt diagnosis.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Cerebrospinal Fluid Leak Following Nasal Packing for Epistaxis

Anterior epistaxis is commonly treated with Merocel nasal packing insertion. A 63-year-old male patient showed a cerebrospinal fluid rhinorrhea and pneumocephalus immediately after insertion of a Merocel tampon used for spontaneous right anterior epistaxis. He later developed fever and headache. This clinical report is to highlight how the nasal merocel should be positioned by specialized personnel and to describe how to manage this type of complication.

Intracranial pressure-based validation and analysis of traumatic brain injury using a new three-dimensional finite element human head model

Traumatic brain injuries are life-threatening injuries that can lead to long-term incapacitation and death. Over the years, numerous finite element human head models have been developed to understand the injury mechanisms of traumatic brain injuries. Many of these models are erroneous and used ellipsoidal or spherical geometries to represent brain. This work is focused on the development of high-quality, comprehensive three-dimensional finite element human head model with accurate representation of cerebral sulci and gyri structures in order to study traumatic brain injury mechanisms. Present geometry, predicated on magnetic resonance imaging data consist of three rudimentary components, that is, skull, cerebrospinal fluid with the ventricular system, and the soft tissues comprising the cerebrum, cerebellum, and brain stem. The brain is modeled as a hyperviscoelastic material. Meshed model with 10 nodes modified tetrahedral type element (C3D10M) is validated against two cadaver-based impact experiments by comparing the intracranial pressures at different locations of the head. Our results indicate a better agreement with cadaver results, specifically for the case of frontal and parietal intracranial pressure values. Existing literature focuses mostly on intracranial pressure validation, while the effects of von Mises stress on brain injury are not analyzed in detail. In this work, a detailed interpretation of neurological damage resulting from impact injury is performed by analyzing von Mises stress and intracranial pressure distribution across numerous segments of the brain. A reasonably good correlation with experimental data signifies the robustness of the model for predicting injury mechanisms based on clinical predictions of injury tolerance criteria.

Rapid Diagnostic Test Kit for Point-of-Care Cerebrospinal Fluid Leak Detection

Cerebrospinal fluid (CSF) leaks can occur when there is communication between the intracranial cavities and the external environment. They are a common and serious complication of numerous procedures in otolaryngology, and if not treated, persistent leaks can increase a patient's risk of developing life-threatening complications such as meningitis. As it is not uncommon for patients to exhibit increased secretions postoperatively, distinguishing normal secretions from those containing CSF can be difficult. Currently, there are no proven, available tests that allow a medical provider concerned about a CSF leak to inexpensively, rapidly, and noninvasively rule out the presence of a leak. The gold standard laboratory-based test requires that a sample be sent to a tertiary site for analysis, where days to weeks may pass before results return. To address this, our group recently developed a semiquantitative, barcode-style lateral-flow immunoassay (LFA) for the quantification of the beta-trace protein, which has been reported to be an indicator of the presence of CSF leaks. In the work presented here, we created a rapid diagnostic test kit composed of our LFA, a collection swab, dilution buffers, disposable pipettes, and instructions. Validation studies demonstrated excellent predictive capabilities of this kit in distinguishing between clinical specimens containing CSF and those that did not. Our diagnostic kit for CSF leak detection can be operated by an untrained user, does not require any external equipment, and can be performed in approximately 20 min, making it well suited for use at the point of care. This kit has the potential to transform patient outcomes.

Determination of cerebrospinal fluid leakage by selective deletion of transferrin glycoform using an immunochromatographic assay

Cerebrospinal fluid (CSF) leakage can lead to brain and spine pathologies and there is an urgent need for a rapid diagnostic method for determining CSF leakage. Beta-2 transferrin (β2TF), asialotransferrin, is a specific CSF glycoprotein biomarker used to determine CSF leakage when distinguished from serum sialotransferrin (sTF).

Methods: We detected β2TF using an immunochromatographic assay (ICA), which can be potentially developed as a point-of-care (POC) testing platform. Sialic acid-specific lectin selectively captures sTF in multiple deletion lines within an ICA test strip, enabling the detection of β2TF. A sample pre-treatment process efficiently captures excess sTF increasing sensitivity for CSF leakage detection.

Results: An optimal cut-off value for determining the presence of CSF in test samples was obtained from receiver operating characteristic (ROC) analysis of the ratio of the test signal intensity and the deletion lines. On 47 clinical samples, ICA test strips discriminated CSF positive from negative samples with statistically significant (positive versus negative t-test; P =0.00027). Additional artificial positive samples, prepared by mixing CSF positive and negative clinical samples, were used as a further challenge. These positive samples were clearly discriminated from the negative samples (mixture versus negative t-test; P =0.00103) and CSF leakage was determined with 97.1% specificity and 96.2% sensitivity.

Conclusions: ICA represents a promising approach for POC diagnosis of CSF leakage. While requiring 70 min assay time inconvenient for POC testing, our method was significantly shorter than conventional electrophoresis-based detection methods for β2TF.

Detection of Cerebrospinal Fluid Leaks: Is There a Radiologic Standard of Care? A Systematic Review

INTRODUCTION

Diagnosis of cerebrospinal fluid (CSF) leaks traditionally involves laboratory testing of markers and appropriate imaging. Surgical localization can be difficult, and the inability to accurately localize skull base defects leads to increased rates of repair failure and complications. Many imaging techniques localizing and identifying CSF leaks have been proposed. Comparisons of current and investigational imaging techniques used to localize CSF leaks are reviewed.

METHODS

A comprehensive and systematic search through PubMed, Scopus, and reference lists from relevant articles was completed to identify literature on sensitivities of different imaging methods for localization and detection of CSF leaks. Prospective, retrospective, and case series published since 1995 that addressed imaging techniques for CSF leaks confined to the skull base were included. Sensitivities of each major imaging technique proposed were recorded and analyzed.

RESULTS

In total, 133 studies initially were screened from 2125 studies on preliminary search. Of these, 38 studies were included based on inclusion criteria. Studies were segregated by imaging modality. A total of 1000 patients with CSF leaks subsequently were evaluated.

CONCLUSIONS

Although radionuclide cisternography has been the historical standard, recent imaging techniques have emerged considering the low sensitivity. Computed tomography cisternography with contrast also has low sensitivity, even in active leaks. Although high-resolution computed tomography is commonly the initial study of choice, magnetic resonance imaging methods, particularly 3-dimensional imaging, may prove to be a more sensitive study of choice. Computed tomography/magnetic resonance imaging combination methods may show promise in localizing CSF leaks. Stratifying by status and etiology may be an important determinant. Further studies investigating various imaging techniques for localizing CSF leaks are needed.

Traumatic cerebrospinal fluid oculorrhea managed with an external ventricular drain

Cerebrospinal fluid (CSF) leaks following head injuries are rare complications with significant morbidity and mortality if left untreated. CSF oculorrhea secondary to a cranio-orbital fistula is a rare presentation of this complication. Standard treatment for a CSF leak involves management of intracranial pressure, CSF diversion and surgical repair of any dural defect. Lumbar drains have commonly been inserted to aid in diverting CSF. We describe a case of a 16-year-old male who presented with an open comminuted depressed skull fracture and CSF oculorrhea. Following a bifrontal decompressive craniectomy, he was successfully treated with CSF diversion following a conservative trial using an external ventricular drain. The use of an external ventricular drain for this purpose has not been described in the literature to date. We report this case as a method of demonstrating the use of an external ventricular drain to adequately divert CSF.

Cerebrospinal fluid rhinorrhea and otorrhea: A multimodality imaging approach

Cerebrospinal fluid (CSF) leaks are extracranial egress of CSF into the adjacent paranasal sinus or tympanomastoid cavity due to an osteodural defect involving skull base. It can be due to a multitude of causes including accidental or iatrogenic trauma, congenital malformations and spontaneous leaks. Accurate localization of the site of the leak, underlying causes and appropriate therapy is necessary to avoid associated complications. In this paper relevant anatomy, clinical diagnosis, imaging modalities and associated findings are discussed along with a brief mention about management.

Skull Base Trauma: Clinical Considerations in Evaluation and Diagnosis and Review of Management Techniques and Surgical Approaches

Traumatic injuries to the skull base can involve critical neurovascular structures and present with symptoms and signs that must be recognized by physicians tasked with management of trauma patients. This article provides a review of skull base anatomy and outlines demographic features in skull base trauma. The manifestations of various skull base injuries, including CSF leaks, facial paralysis, anosmia, and cranial nerve injury, are discussed, as are appropriate diagnostic and radiographic testing in patients with such injuries. While conservative management is sometimes appropriate in skull base trauma, surgical access to the skull base for reconstruction of traumatic injuries may be required. A variety of specific surgical approaches to the anterior cranial fossa are discussed, including the classic anterior craniofacial approach as well as less invasive and newer endoscope-assisted approaches to the traumatized skull base.

Visual and Quantitative Analysis of Cisternography for the Detection of Cerebrospinal Fluid Leakage

We herein present a case of a 29-year-old man with clear rhinorrhea, which persisted for 8 years following a myringotomy. After cotton pledgets were placed in several different regions of the nasal cavity, cisternography using Tc-99m DTPA was performed to measure the radioactivity of each pledget. Cisternography showed subtle uptake in the nasal cavity. However, intense uptake was detected in the pledget placed in the right eustachian tube orifice, where the pledget:serum count ratio was 10.3:1. The patient underwent duroplasty and cranioplasty, and the rhinorrhea resolved.

Beta-trace Protein as a new non-invasive immunological Marker for Quinolinic Acid-induced impaired Blood-Brain Barrier Integrity

Quinolinic acid, a macrophage/microglia-derived excitotoxin fulfills a plethora of functions such as neurotoxin, gliotoxin, and proinflammatory mediator, and it alters the integrity and cohesion of the blood-brain barrier in several pathophysiological states. Beta-trace protein (BTP), a monomeric glycoprotein, is known to indicate cerebrospinal fluid leakage. Thus, the prior aim of this study was to investigate whether BTP might non-invasively indicate quinolinic acid-induced impaired blood-brain barrier integrity. The research hypotheses were tested in three subsamples with different states of immune activation (patients with HCV-infection and interferon-α, patients with major depression, and healthy controls). BTP has also been described as a sensitive marker in detecting impaired renal function. Thus, the renal function has been considered. Our study results revealed highest quinolinic acid and highest BTP- levels in the subsample of patients with HCV in comparison with the other subsamples with lower or no immune activation (quinolinic acid: F = 21.027, p < 0.001 [ANOVA]; BTP: F = 6.792, p < 0.01 [ANOVA]). In addition, a two-step hierarchical linear regression model showed that significant predictors of BTP levels are quinolinic acid, glomerular filtration rate and age. The neurotoxin quinolinic acid may impair blood-brain barrier integrity. BTP might be a new non-invasive biomarker to indicate quinolinic acid-induced impaired blood-brain barrier integrity.

Management of CSF leak in base of skull fractures in adults

AIMS

CSF leaks are not uncommon after a base of skull fracture. Currently there is no standardised algorithm for the investigation and management of post-traumatic CSF leaks. In this paper we aim to provide an evidence-based framework for managing post-traumatic CSF leaks.

METHODS

We searched the English literature over the past 45 years using CINAHL, EMBASE and MEDLINE for the terms (1) post-traumatic CSF leaks or fistulas, and (2) basilar or base of skull fractures, but excluded papers on post-operative and non-traumatic CSF leaks, and papers on paediatric post- traumatic CSF leaks.

RESULTS

The diagnosis of a base of skull fracture and any resultant CSF leak can be challenging. Therefore a combination of biochemical and radiological studies are needed to optimise the diagnosis of this condition. Post-traumatic CSF leaks are generally treated conservatively, and a majority of them resolve without further surgical management. However for patients who are refractory to such treatments, surgical closure of the CSF fistula is necessary. Surgical obliteration of CSF leaks can be challenging and requires the involvement of multiple surgical specialties such as neurosurgery, otolaryngology, and maxillofacial surgery.

CONCLUSION

Although we have formulated a simple algorithm to aid the investigation and management of post-traumatic CSF leaks, there are still many important unresolved questions requiring further well powered studies to answer.

A modification of endoscopic endonasal approach for management of encephaloceles in sphenoid sinus lateral recess

Spontaneous cerebrospinal fluid leak with meningoencephaloceles in sphenoid sinus lateral recess is challenging. Transnasal visualization of this area is difficult, especially when large pneumatization is present. External approaches to this region involve aggressive surgery and are often associated with significant morbidity. The aim of this study is to assess the real effectiveness of a modification of the endoscopic endonasal approach for their management. This is a prospective case series study and was conducted at Otolaryngology department, Ain Shams University Hospitals, Cairo, Egypt. Seven patients with spontaneous cerebrospinal fluid leak with meningoencephaloceles in the sphenoid sinus lateral recess were included. Diagnosis was confirmed by: analysis for beta-2 transferrin and imaging. They were managed with endoscopic endonasal retrograde trans-sphenoid approach described in this study with multilayered reconstruction of the defect. Mean age of our patients was 40.14 ± 8.35 years; mean BMI was 36.37 ± 2.59 kg/m². Primary empty sella was present and osteodural defect was identified in superior wall of sphenoid sinus lateral recess with punched out and regular smooth edges. Mean intra-cranial pressure was (26.42 ± 3.87 mmH₂O) and size of defect was less than 10 mm, mean 7.85 ± 1.34. Mean-operative time was 169.28 ± 21.87 min. The mean hospital stay was 7.42 ± 1.39 days. No cerebrospinal fluid leak recurrences were observed during follow-up period that ranged from 37 to 48 months. Endoscopic endonasal retrograde trans-sphenoid approach provides a wide, safe, and direct route to the management of sphenoid sinus lateral recess cerebrospinal fluid leak.

Management of Anterior Skull Base Cerebrospinal Fluid Leaks

Cerebrospinal fluid (CSF) leak occurs from traumatic, iatrogenic, and idiopathic etiologies. Its timely diagnosis requires clinical, radiographic, and laboratory testing. Medical and surgical management can mitigate the risk of life-threatening infection and morbidity. This article outlines the pathophysiology, diagnosis, and management or CSF leak of the anterior skull base.

Endoscopic Endonasal Repair of Spontaneous and Traumatic Cerebrospinal Fluid Rhinorrhea: A Review and Local Experience

This article presents an overview of endoscopic endonasal repair of cerebrospinal fluid (CSF) rhinorrhea. In recent years, endoscopic repair has become the standard of care for managing this condition, because it gradually replaces the traditional open transcranial approach. Discussion includes the etiologic classification of CSF rhinorrhea, management paradigm for each category, diagnosis algorithm, comprehensive description of the surgical technique, and an updated review of the literature regarding the safety and efficacy of this procedure. In addition, the authors present their experience, including 2 surgical videos demonstrating endoscopic repair of CSF rhinorrhea in 2 distinct clinical scenarios.

Patterns and sequelae of sphenoid sinus fractures

BACKGROUND

The sphenoid sinus is one of the most commonly fractured regions of the skull base after blunt head trauma. These fractures may be associated with complications such as blunt carotid artery injury (BCAI) and cerebrospinal fluid (CSF) leak. Association of these sequelae with sphenoid sinus fractures has yet to be analyzed thoroughly in the literature.

OBJECTIVE

Analyze patterns of traumatic sphenoid sinus fractures and assess relationships between fracture patterns and incidence of BCAI and traumatic nasal CSF leaks.

METHODS

A retrospective review of 123 patients sustaining sphenoid sinus fractures was performed. Patient medical records and radiographic images were reviewed. Fractures were classified based on the sinus walls involved. Logistic and linear regressions were used to analyze associations between injury mechanisms, fracture subsites, and sequelae.

RESULTS

The most commonly fractured sphenoid sinus subsites included the carotid canal, sphenoid roof, and lateral wall (60%, 49% and 48%, respectively). CSF leaks occurred in 9% of sphenoid sinus fractures, whereas BCAI occurred in 1.6%. On logistic regression, sphenoid roof fractures were significantly associated with CSF leaks (odds ratio [OR] = 12.4, p = 0.002). No fracture subsite was associated with BCAI. The positive predictive value (PPV) of sphenoid roof fractures for the presence of CSF leaks was 17%, whereas the negative predictive value (NPV) was 98%. The PPV of carotid canal fractures for BCAI was 3%, whereas the NPV was 100%. There was no association between the number of fractured sinus walls and the incidence of BCAI or CSF leak. Penetrating injuries were significantly associated with CSF leak (OR = 24.7, p = 0.01), but no other injury mechanisms were associated with BCAI or CSF leak.

CONCLUSION

Nasal CSF leak was the most common sequela of sphenoid sinus fractures, whereas BCAI was extremely uncommon. Analysis of fracture patterns can be useful in determining the need for additional evaluation.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

[Trauma of the anterior floor of the base of the skull: about a series of 136 cases]

Les traumatismes de l’étage antérieur de la base du crâne représentent 15 à 20% des traumatismes crâniens en général. Ils menacent les structures neuro-encéphaliques sus jacentes et sont très souvent responsables de brèches ostéo-méningées exposant au risque infectieux. Notre travail a concerné 136 dossiers exploitables de traumatisme de l’étage antérieur de la base du crâne colligés sur une période de 10 ans entre janvier 2003 et décembre 2012. Le diagnostic a été suspecté devant les signes cliniques évocateurs (ecchymose péri-orbitaire, rhinorrhée…) et a été confirmé dans la plupart des cas par la TDM. Le traitement idéal est la fermeture chirurgicale de la brèche en association aux moyens médicaux (vaccination, anti-épileptiques, mesures de réanimation…) Le moment idéal de la réparation est au-delà de la 72^ème heure après la diminution de l'oedème cérébral en cas d'absence d'une lésion intracrânienne nécessitant une intervention en urgence. Notre équipe ne pratiquant pas la voie endoscopique, l'abord frontal est souvent indiqué. Le pronostic dépend des lésions cérébrales associées et surtout de la présence d'une brèche dont le diagnostic et la réparation doivent être les plus rapides et les plus précis possibles. Ainsi toute rhinorrhée post-traumatique nécessite une exploration systématique, le timing idéal: c'est la disparition de l'oedème cérébral pour faciliter l'exploration, ceci est en général possible à partir de la 72^ème heure sauf dans les cas associés à une autre lésion intra crânienne nécessitant une exploration en urgence.