Diagnosis and surgical management of traumatic cerebrospinal fluid oculorrhea: case report and systematic review of the literature

A Novel Combined Transorbital Transnasal Endoscopic Approach for Reconstruction of Posttraumatic Complex Anterior Cranial Fossa Defect

The transorbital neuroendoscopic surgery (TONES), endoscopic transnasal skull base procedures, and the concept of multiportal minimal access neurosurgery are novel, rapidly evolving approaches in the management of complex skull base lesions. A 27-year-old male presented with a history of road traffic accident with nasal bleed, cerebrospinal fluid (CSF) rhinorrhea, and left eye deformity. There was left upper eyelid ecchymosis, orbital dystopia, left pupil was dilated, and fixed with no extraocular movements. The computed tomography scan showed basifrontal contusion and complex comminuted anterior cranial fossa (ACF) fracture involving left cribriform plate and left orbital roof with fracture fragment impinging on the superior rectus muscle with suspicious orbital CSF leak. There was no improvement with conservative management. Hence, a novel combined TONES, transnasal endoscopic multiportal surgery was undertaken for the removal of fracture fragments and multi-layered closure of the complex ACF defect. The patient had a complete resolution of orbital dystopia and visual loss with no evidence of CSF leak postoperatively.

CSF Oculorrhea Presenting as "Tearing" following the Repair of Fronto-Ethmoidal Encephalocele

INTRODUCTION

Cerebrospinal fluid (CSF) oculorrhea is extremely rare, and very few cases have been reported mostly following trauma. There is only 1 case in the published literature where oculorrhea occurred following the repair of fronto-nasal encephalocele.

CASE DESCRIPTION

A six-year-old girl presented with gradually increasing fronto-ethmoidal encephalocele with secondary papulo-nodular changes. She underwent bi-frontal craniotomy with excision of encephalocele sac and herniated gliotic brain followed by dural closure using peri-cranial graft. One month later, she presented again with swelling over the operative site and "tearing" from both her eyes. She was diagnosed with CSF oculorrhea. After failing conservative management, lumbar drain was inserted and kept on continuous drainage. Oculorrhea stopped with lumbar drain but restarted with its removal. Therefore, theco-peritoneal shunt was placed, following which oculorrhea stopped. She is doing well at 5 months' follow-up.

CONCLUSION

CSF oculorrhea must be considered by the pediatric neurosurgeons in any patient who presents with "tearing" following the repair of an anterior encephalocele.

Head Injuries in Homer's Iliad

The Iliad is an epic poem chronicling the journey of Achilles in the Trojan War. The poem is one of the earliest sources of written literature in the Western canon. It is not a medical text, but the many and varied descriptions of injuries and their consequences mean that it is an important source for examining the earliest notions of anatomy and knowledge of the pathologies that result from trauma. Head injuries feature prominently in the text and represent written accounts of neurotrauma from nearly 3000 years ago. Previous work on the poem has suggested an awareness of neurological concepts such as nystagmus, syncope, and pupillary dilatation after trauma. In this paper, we identify and categorize all of the head injuries detailed in the text and examine these to identify concepts of functional neuroanatomy that are revealed by the descriptions. We identify and discuss 2 detailed descriptions of head injury, suggesting an awareness of decerebrate posturing after brainstem injury and cerebrospinal fluid leakage following a basal skull fracture.

Rational design of secondary operation for penetrating head injury: A case report

Penetrating head injury is rare, and thus management of such injuries is non-standard. Early diagnosis and intraoperative comprehensive exploration are necessary considering the complexity and severity of the trauma. However, because of the lack of microsurgical techniques in local hospitals, the possible retained foreign bodies and other postoperative complications such as cerebrospinal fluid (CSF) leak usually require a rational design for a secondary operation to deal with. We present a case of a 15-year-old boy who was stabbed with a bamboo stick in his left eye. The chopsticks passed through the orbit roof and penetrated the skull base. In subsequent days, the patient sustained CSF leak and intracranial infection after an unsatisfied primary treatment in the local hospital and had to request a secondary operation in our department. Computed tomography including plain scan, three dimension reconstruction and computed tomographic angiography are used to determine the course and extent of head injury. A frontal craniotomy was performed. Three pieces of stick were found residual and removed with the comminuted orbit bone fragments. A pedicled temporalis muscle fascia graft was applied to repair the frontier skull base and a free temporalis muscle flap to seal the frontal sinus defect. Aggressive broad-spectrum antibiotics of vancomycin and meropenem were administrated for persistent fever after operation. CSF external drainage system continued for 12 days, and was removed 10 days after temperature returned to normal. The Glasgow coma scale score was improved to 15 at postoperative day 7 and the patient was discharged at day 22 uneventfully. We believe that appropriate preoperative surgical plan and thorough surgical exploration by microsurgery is essential for attaining a favorable outcome, especially in secondary operation. Good postoperative recovery depends on successfully management before and after operation for possible complications as well.

Post-traumatic orbitorrhea: An underestimated life-threatening complication following anterior skull base fractures

Orbitorrhea is defined as a leak of cerebrospinal fluid from a cranio-orbital fistula. It is usually related to anterior skull base trauma. Orbitorrhea is an exceptional and life-threatening condition which should be promptly managed. We herein report the case of a right post-traumatic orbitorrhea following anterior skull base trauma. Conservative treatment was initially attempted. At 6 weeks, recurrence was noted, and the patient underwent neurosurgical management. A few months later, a secondary upper lid retraction was diagnosed and treated by full-thickness skin graft with favourable outcome. To our knowledge, fewer than 30 cases have been previously reported. Ophthalmologists should be aware of this life-threatening condition which could be underestimated.

Orbital Trauma

The orbit is contained within a complex bony architecture with overlying soft tissue that involves many important anatomical structures. Orbital trauma is a frequent cause of damage to these structures. The authors review the literature on reconstructive techniques focusing on fractures of the orbital rim, orbital roof, orbital floor, medial orbital wall, and naso-orbito-ethmoid complex. A thorough literature review was conducted using PubMed analyzing articles relevant to the subject matter. Various search terms were used to identify articles regarding orbital trauma presentation, diagnosis, management, as well as postoperative complications. Articles were examined by all authors and pertinent information was gleaned for the purpose of generating this review. Orbital trauma can result in a wide variety of complications in form and function. Not all orbital fractures require operative repair. However, bony disruption can cause enophthalmos, hypophthalmos, telecanthus, epiphora, cerebrospinal fluid leaks, orbital hematoma, and even blindness to name a few. Timing of operative repair as well as reconstructive method is dictated by the patient's individual presentation. Successful fracture management requires a detailed understanding of the anatomy and pathophysiology to ensure restoration of the patients' preoperative state. Orbital trauma encompasses a wide variety of mechanisms of injury and resulting fracture patterns. A variety of surgical approaches to the orbit exist as has been discussed allowing the surgeon access to all area of interest. Regardless of the fracture complexity, the principles of atraumatic technique, anatomic reduction, and stable fixation apply in all cases.

Olfaction written in bone: cribriform plate size parallels olfactory receptor gene repertoires in Mammalia

The evolution of mammalian olfaction is manifested in a remarkable diversity of gene repertoires, neuroanatomy and skull morphology across living species. Olfactory receptor genes (ORGs), which initiate the conversion of odorant molecules into odour perceptions and help an animal resolve the olfactory world, range in number from a mere handful to several thousand genes across species. Within the snout, each of these ORGs is exclusively expressed by a discrete population of olfactory sensory neurons (OSNs), suggesting that newly evolved ORGs may be coupled with new OSN populations in the nasal epithelium. Because OSN axon bundles leave high-fidelity perforations (foramina) in the bone as they traverse the cribriform plate (CP) to reach the brain, we predicted that taxa with larger ORG repertoires would have proportionately expanded footprints in the CP foramina. Previous work found a correlation between ORG number and absolute CP size that disappeared after accounting for body size. Using updated, digital measurement data from high-resolution CT scans and re-examining the relationship between CP and body size, we report a striking linear correlation between relative CP area and number of functional ORGs across species from all mammalian superorders. This correlation suggests strong developmental links in the olfactory pathway between genes, neurons and skull morphology. Furthermore, because ORG number is linked to olfactory discriminatory function, this correlation supports relative CP size as a viable metric for inferring olfactory capacity across modern and extinct species. By quantifying CP area from a fossil sabertooth cat (Smilodon fatalis), we predicted a likely ORG repertoire for this extinct felid.

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.

Posttraumatic Oculorrhea From the Eyelid

We report a 21-month-old boy with a sutured laceration of the left upper eyelid with drainage of cerebrospinal fluid. Careful evaluation, including computerized tomography, revealed a penetrating injury of the left orbital wall and a linear bone fracture. The wound was resutured carefully. There was no cerebrospinal fluid leakage in the postoperative follow-up period.

Eyelid Edema: A Rare Cause of a Common Sign

We report a 48-year-old female patient who presented to the emergency room with right eyelid edema, with 3 days of evolution. She had suffered minor trauma to this eye one week before. She reported episodes of right eyelid swelling of spontaneous resolution since the occurrence of a traumatic brain injury 5 years ago. Ophthalmological examination showed a soft and painless eyelid edema of the right eye. Brain computed tomography showed an area of bone discontinuity of the orbital roof with brain herniation and a CSF leak into the eyelid (blepharocele). Magnetic resonance confirmed the result of TC and revealed an area of frontal encephalomalacia. Ibuprofen (800 mg/day) was prescribed, with complete resolution within 20 days. She was evaluated by Neurosurgery with no indication of surgery due to the resolution of the edema and absence of symptoms. Blepharocele is a rare entity that should be considered in the differential diagnosis of unilateral eyelid edema. It can be secondary to an orbital fracture or congenital lesion.

Nonmissile Penetrating Head Injuries: Surgical Management and Review of the Literature

BACKGROUND

Nonmissile penetrating head injuries (NPHIs) in the civilian population are rare but potentially fatal. Although numerous cases have been reported in the literature, the surgical management of such injuries is still ambiguous, especially with development of surgical techniques. Here, we report 5 cases of NPHIs managed with different surgical techniques and review the literature on surgical treatment of these injuries to outline the appropriate management for these patients from a neurosurgical perspective.

METHODS

We retrospectively reviewed 5 cases of NPHIs managed surgically in our department. The clinical data were collected, including cause, type of objects, way of penetration, initial clinical evaluation, imaging, surgical intervention, postoperative care, complication, follow-up, and outcome. In addition, a systematic review of the literature was performed in the PubMed database to search for articles on surgical treatment of these injuries.

RESULTS

These 5 cases were caused by twisted steel bar, electric welding rod, and sewing needle, respectively. Preoperative imaging, including computed tomography, magnetic resonance imaging, and digital subtraction angiography, was selectively performed to assist the operative plan. Foreign objects were removed surgically in all cases. Postoperative prophylactic administration of antibiotics and anticonvulsants was used to prevent infectious and epileptic complications. Most of the patients achieved a better outcome except for one.

CONCLUSIONS

NPHIs can be fatal but they can be managed with satisfactory results by proper preoperative imaging evaluation, rapid appropriate surgical management, and accurate postoperative care. Personalized surgical intervention should be undertaken depending on the mechanism and extent of the NPHI.

Trauma of the midface

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

Traumatic orbital CSF leak

Compared to the cerebrospinalfluid (CSF) leak through the nose and ear, the orbital CSF leak is a rare and underreported condition following head trauma. We present the case of a 49-year-old woman with oedematous eyelid swelling and ecchymosis after a seemingly trivial fall onto the right orbit. Apart from the above, she was clinically unremarkable. The CT scan revealed a minimally displaced fracture of the orbital roof with no emphysema or intracranial bleeding. The fractured orbital roof in combination with the oedematous eyelid swelling raised the suspicion for orbital CSF leak. The MRI of the neurocranium demonstrated a small-sized CSF fistula extending from the anterior cranial fossa to the right orbit. The patient was treated conservatively and the lid swelling resolved completely after 5 days. Although rare, orbital CSF leak needs to be included in the differential diagnosis of periorbital swelling following orbital trauma.