1
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Liao JC, Liang B, Wang XY, Huang JH. Cerebrospinal fluid leak management in anterior basal skull fractures secondary to head trauma. Neurol Res 2022; 44:888-893. [PMID: 35438605 DOI: 10.1080/01616412.2022.2066783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Jian-Cheng Liao
- Department of Neurosurgery, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
| | - Buqing Liang
- Department of Neurosurgery, Baylor Scott & White Medical Center, Temple, Texas, USA.,Department of Surgery, Texas A&M University College of Medicine, Temple, Texas, USA Texas
| | - Xiang-Yu Wang
- Department of Neurosurgery, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
| | - Jason H Huang
- Department of Neurosurgery, Baylor Scott & White Medical Center, Temple, Texas, USA.,Department of Surgery, Texas A&M University College of Medicine, Temple, Texas, USA Texas
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2
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Shelesko EV, Chernikova NA, Kravchuk AD, Strunina YV, Okhlopkov VA, Belov AI. [Multiple skull base defects: features of pathogenesis, diagnosis and treatment]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:58-63. [PMID: 34463451 DOI: 10.17116/neiro20218504158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine the risk factors of multiple skull base defects, as well as features of diagnosis and treatment of this pathology. MATERIAL AND METHODS A retrospective analysis included 39 patients who underwent surgery for nasal CSF leakage at the Burdenko Neurosurgical Center in 2000-2019. The study recruited patients with multiple simultant skull base defects. RESULTS Traumatic defects were observed in 23 (59%) patients, spontaneous defects - in 16 (41%) cases. All patients underwent endoscopic endonasal closure of skull base defects with autografts. CONCLUSION Multiple defects are more common in severe traumatic brain injury. The main risk factors of multiple spontaneous defects are female sex and overweight. Adequate diagnosis implies high-resolution CT (slice width 0.5-1 mm), as well as intraoperative control of all suspicious and «weak» areas. Endoscopic endonasal technique is effective and safe for multiple skull base defects (efficiency 97%).
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Affiliation(s)
| | | | | | | | | | - A I Belov
- Burdenko Neurosurgical Center, Moscow, Russia
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3
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Seok H, Im SB, Hwang SC. Reconstruction of Anterior Skull Base Fracture Using Autologous Fractured Fragments: A Simple Stitching-Up Technique. Korean J Neurotrauma 2021; 17:25-33. [PMID: 33981640 PMCID: PMC8093017 DOI: 10.13004/kjnt.2021.17.e7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 03/18/2021] [Indexed: 11/20/2022] Open
Abstract
Objective A displaced fracture in the anterior cranial base may be complicated by cerebrospinal fluid (CSF) rhinorrhea and enophthalmos. This study introduces a reconstruction technique with direct dural repair and reduction and fixation of the autologous fractured fragments. Methods Displaced fractures in the anterior cranial base were reconstructed using a stitching-up technique: A bicoronal scalp incision and frontal craniotomy was performed and the displaced bone was withdrawn. The lacerated dura was repaired primarily using a graft. Small holes were created in the intact cranial bones and the displaced harvest bone. Black silk was passed through the holes and the displaced bone was repositioned on tying the silk. Lumbar drain was not placed in any of the cases. The feasibility and outcome were evaluated. Results Five patients with displaced skull fractures of the anterior cranial base were included. All cases were men who had a direct impact on the forehead and/or eye. All the displaced fractures occurred in the orbital roof, and ethmoid bone fractures were present in 4 cases. Dural laceration was involved in 4 cases and repaired by placing artificial dura in 3 cases and a pericranial graft in 1 case. Following surgery, all cases were uneventful, and the anterior cranial fossa was well reconstructed. CSF leakage or enophthalmos did not occur in any of the cases. Conclusion Direct dural repair and autologous stitching-up reconstruction using the fractured fragment could be an effective method to prevent CSF leakage and enophthalmos in displaced fractures of the anterior cranial base.
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Affiliation(s)
- Hoon Seok
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Soo-Bin Im
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Sun-Chul Hwang
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
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4
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Ceraudo M, Prior A, Balestrino A, Anania P, Camera M, Fiaschi P, Gatto F, Riccardi N, Zona G, Criminelli Rossi D. Ultra-short antibiotic prophylaxis guided by preoperative microbiological nasal swabs in endoscopic endonasal skull base surgery. Acta Neurochir (Wien) 2021; 163:369-382. [PMID: 32901395 DOI: 10.1007/s00701-020-04560-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 08/27/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE Endoscopic endonasal skull base surgery (EESBS) is a clean-contaminated procedure. Guidelines regarding the antibiotic prophylaxis in EESBS have not been developed yet, and today, there are no universally accepted protocols. In this article, we investigated the efficacy of our new ultra-short antibiotic prophylaxis protocol for EESBS guided by the cultural results of preoperative microbiological nasal swabs. METHODS We defined as "nasal swab-related antibiotic protocol" the administration of a first-generation cephalosporin (cefazolin 2 g) in patients whose nasal swabs revealed the presence of normal nasal flora or methicillin-sensitive Staphylococcus aureus (MSSA), and the administration of vancomycin 1 g intravenously in patients whose nasal swabs revealed the presence of methicillin-resistant Staphylococcus aureus (MRSA) or with reported cephalosporin/penicillin allergy. This case-control study included 120 patients who underwent EESBS. The case group included 60 cases who received the "nasal swab-related antibiotic protocol," while the control group included 60 cases who received the "standard hospital antibiotic protocol" used in neurosurgery (cefazolin 2 g plus metronidazole 500 mg at induction, and 2 g of cefazolin repeated after 180 min). RESULTS The preoperative microbiological nasal swabs showed normal nasal flora in 42 patients (70%), MSSA in 17 patients (28.3%), and MRSA in 1 patient (1.6%). During the study period, no cases of meningitis or sinusitis occurred in the case group ("nasal swab-related antibiotic protocol"), while two infections (3.3%, 1 sinusitis and 1 meningitis) were reported in the control group ("standard hospital antibiotic protocol"). Mean length of hospitalization was 6.5 days for the case group and 8.5 days in the control group. "Standard hospital antibiotic protocol" is less expensive (range, 2.88-5.42 euros) compared with our new "nasal swab-related antibiotic protocol" (range, 10.02-32.56 euros), but in line with other antibiotic prophylaxis protocols reported in literature. DISCUSSION The low complication rates of our case series (0%) is comparable to complication rates reported in literature (1.6% for meningitis and 8% for sinusitis). Compared with other perioperative antibiotic regimens reported in literature, the "nasal swab-related antibiotic protocol" is cheap and at least equally effective. We discuss the rationale on which we based the choice of chemoprophylaxis, the timing, and the length of our regimen. CONCLUSIONS Our study confirmed the safety and efficacy of our easily applicable and low-cost antibiotic prophylaxis protocol.
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Affiliation(s)
- M Ceraudo
- Division of Neurosurgery, San Martino- IST University Hospital (IRCCS), Genoa, Italy.
| | - A Prior
- Division of Neurosurgery, San Martino- IST University Hospital (IRCCS), Genoa, Italy
| | - A Balestrino
- Division of Neurosurgery, San Martino- IST University Hospital (IRCCS), Genoa, Italy
| | - P Anania
- Division of Neurosurgery, San Martino- IST University Hospital (IRCCS), Genoa, Italy
| | - M Camera
- Department of Infectious - Tropical Diseases and Microbiology, IST University Hospital (IRCCS), Genoa, Italy
| | - P Fiaschi
- Division of Neurosurgery, San Martino- IST University Hospital (IRCCS), Genoa, Italy
- Division of Neurosurgery, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, San Martino - IST University Hospital (IRCCS), Genoa, Italy
| | - F Gatto
- Endocrinology Unit, San Martino - IST University Hospital (IRCCS), Genoa, Italy
| | - N Riccardi
- Department of Infectious - Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | - G Zona
- Division of Neurosurgery, San Martino- IST University Hospital (IRCCS), Genoa, Italy
- Division of Neurosurgery, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, San Martino - IST University Hospital (IRCCS), Genoa, Italy
| | - D Criminelli Rossi
- Division of Neurosurgery, San Martino- IST University Hospital (IRCCS), Genoa, Italy
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5
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Ter Horst L, Brouwer MC, van der Ende A, van de Beek D. Community-acquired Bacterial Meningitis in Adults With Cerebrospinal Fluid Leakage. Clin Infect Dis 2021; 70:2256-2261. [PMID: 31300817 PMCID: PMC7245152 DOI: 10.1093/cid/ciz649] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/11/2019] [Indexed: 02/07/2023] Open
Abstract
Background Cerebrospinal fluid (CSF) leakage is a risk factor for developing bacterial meningitis. Methods We analyzed episodes of community-acquired bacterial meningitis associated with CSF leakage from a prospective nationwide cohort study. Results CSF leakage was identified in 65 episodes of 2022 episodes (3%) in 53 patients. The cause of CSF leakage was identified in 49 of 65 episodes (75%), which most commonly consisted of ear-nose-throat surgery (19 of 49 episodes [29%]) and remote head trauma (15 of 49 episodes [23%]). The episode was a recurrent meningitis episode in 38 patients (59%). Of the recurrent episodes, 27 had known CSF leakage (71%) of whom 20 (53%) had previous surgery aiming to close the leak. Nine patients (38%) with known CSF leakage had been vaccinated (23-valent pneumococcal vaccine in 9 patients, meningococcal serogroup C vaccine in 2, meningococcal serogroup A and Haemophilus influenzae type b vaccine each in 1 patient). Streptococcus pneumoniae was cultured in 33 episodes (51%) and H. influenzae in 11 episodes (17%). The most common pneumococcal serotypes were 3 (4 episodes), 35B, 9N, 38, and 15C (each 2 episodes). Haemophilus influenzae was unencapsulated in all 10 episodes with known capsule type. The outcome was unfavorable in 8 episodes (12%) and no patient died. Conclusions Bacterial meningitis in patients with CSF leakage has a high recurrence rate, despite surgical repair or vaccination, and outcome is generally favorable. CSF leakage should be suspected in patients with bacterial meningitis presenting with liquorrhea, recurrent meningitis, or with disease caused by H. influenzae.
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Affiliation(s)
- Liora Ter Horst
- Department of Neurology, Amsterdam Neuroscience, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Matthijs C Brouwer
- Department of Neurology, Amsterdam Neuroscience, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Arie van der Ende
- Department of Medical Microbiology, Amsterdam Infection and Immunity, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands.,Netherlands Reference Laboratory for Bacterial Meningitis, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
| | - Diederik van de Beek
- Department of Neurology, Amsterdam Neuroscience, Amsterdam University Medical Centers, University of Amsterdam, The Netherlands
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6
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Milton CK, Andrews BJ, Baker CM, O'Connor KP, Conner AK, Sughrue ME, McKinney KA, El Rassi ET, Sanclement JA, Glenn CA. Primary Repair of Posteriorly Located Anterior Skull Base Dural Defects Using Nonpenetrating Titanium Clips in Cranial Trauma. J Neurol Surg B Skull Base 2020; 83:116-124. [DOI: 10.1055/s-0040-1718765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 08/19/2020] [Indexed: 10/22/2022] Open
Abstract
Abstract
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.
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Affiliation(s)
- Camille K. Milton
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Bethany J. Andrews
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Cordell M. Baker
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Kyle P. O'Connor
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Andrew K. Conner
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Michael E. Sughrue
- Department of Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Kibwei A. McKinney
- Department of Otorhinolaryngology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Edward T. El Rassi
- Department of Otorhinolaryngology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Jose A. Sanclement
- Department of Otorhinolaryngology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Chad A. Glenn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
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7
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Stopa BM, Leyva OA, Harper CN, Truman KA, Corrales CE, Smith TR, Gormley WB. Decreased Incidence of CSF Leaks after Skull Base Fractures in the 21st Century: An Institutional Report. J Neurol Surg B Skull Base 2020; 83:59-65. [DOI: 10.1055/s-0040-1716689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/25/2020] [Indexed: 10/23/2022] Open
Abstract
Abstract
Objectives Cerebrospinal fluid (CSF) leaks are a possible complication in patients with skull base fractures (SBFs). The widely cited incidence of CSF leaks is 10 to 30% in SBF patients; however, this estimate is based only on a few outdated studies. A recent report found CSF leaks in <2% SBF patients, suggesting the incidence may be lower now. To investigate this, we report here our institutional series.
Design This study is a retrospective chart review.
Setting The study was conducted at two major academic medical centers (2000–2018).
Participants Adult patients with SBF were included in this study.
Main Outcome Measures Variables included age, gender, CSF leak within 90 days, management regimen, meningitis within 90 days, and 1-year mortality.
Results Among 4,944 patients with SBF, 199 (4%) developed a CSF leak. SBF incidence was positively correlated with year of clinical presentation (r-squared 0.78, p < 0.001). Among CSF leaks, 42% were conservatively managed, 52% were treated with lumbar drain, and 7% required surgical repair. Meningitis developed in 28% CSF leak patients. The 1-year mortality for all SBF patients was 11%, for patients with CSF leaks was 12%, and for patients with meningitis was 16%.
Conclusion In the largest institutional review of SBF patients in the 21st century, we found CSF leak incidence to be 4%. This is lower than the widely cited range of 10 to 30%. Nevertheless, morbidity and mortality associated with this complication remains clinically significant, and SBF patients should continue to be monitored for CSF leaks. We provide here our institutional treatment algorithm for these patients that may help to inform the treatment strategy at other institutions.
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Affiliation(s)
- Brittany M. Stopa
- Department of Neurosurgery, Computational Neuroscience Outcomes Center at Harvard, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia, United States
| | - Oscar A. Leyva
- Department of Neurosurgery, Computational Neuroscience Outcomes Center at Harvard, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - Cierra N. Harper
- Department of Neurosurgery, Computational Neuroscience Outcomes Center at Harvard, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Howard University College of Medicine, Washington, Dist. of Columbia, United States
| | - Kyla A. Truman
- Department of Neurosurgery, Computational Neuroscience Outcomes Center at Harvard, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - C. Eduardo Corrales
- Harvard Medical School, Boston, Massachusetts, United States
- Division of Otolaryngology, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Timothy R. Smith
- Department of Neurosurgery, Computational Neuroscience Outcomes Center at Harvard, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
| | - William B. Gormley
- Department of Neurosurgery, Computational Neuroscience Outcomes Center at Harvard, Brigham and Women's Hospital, Boston, Massachusetts, United States
- Harvard Medical School, Boston, Massachusetts, United States
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8
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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9
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Sivanandapanicker J, Nagar M, Kutty R, Sunilkumar BS, Peethambaran A, Rajmohan BP, Asher P, Shinihas VP, Mohandas K, Jain S, Sharma S. Analysis and Clinical Importance of Skull Base Fractures in Adult Patients with Traumatic Brain Injury. J Neurosci Rural Pract 2019; 9:370-375. [PMID: 30069094 PMCID: PMC6050782 DOI: 10.4103/jnrp.jnrp_38_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
| | - Milesh Nagar
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Raja Kutty
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | - B S Sunilkumar
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Anilkumar Peethambaran
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | - B P Rajmohan
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Prasanth Asher
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | - V P Shinihas
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | - K Mohandas
- Department of General Surgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Sourabh Jain
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Saurabh Sharma
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
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10
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Updated Review of Traumatic Dislocation of the Mandibular Condyle Into the Middle Cranial Fossa. J Oral Maxillofac Surg 2019; 77:132.e1-132.e16. [DOI: 10.1016/j.joms.2018.09.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 09/10/2018] [Accepted: 09/11/2018] [Indexed: 12/19/2022]
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11
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Abstract
Background: Timely, expeditious and appropriate management of Frontal bone fractures and associated Frontal Sinus (FS) injuries are both crucial as well as challenging. Treatment options vary considerably, depending upon the nature, extent and severity of these injuries as well as operator skill, expertise and experience. In cases of posterior table fractures of the Frontal Sinus, literature reports have in general, propounded direct visualization and exploration of the sinus via a bifrontal craniotomy, followed by sinus cranialization. Aims and Objectives: To review the standard protocols of management of Frontal bone fractures and Frontal Sinus injuries. To assess the efficacy of a more conservative approach in the management of outer and inner table fractures of the FS. Materials and Methods: Contemporary and evolving management protocols and changing treatment paradigms of different types and severities of frontal bone fractures and frontal sinus injuries, have been presented in this case series. A useful Treatment Algorithm has been proposed to efficiently and effectively manage these injuries. Results: In the present case series, effective and satisfactory results could be achieved in cases of significantly displaced inner and outer table fractures of the Frontal sinus by a more conservative protocol comprising of open reduction and internal fixation carried out via the existing scar of injury, without having to resort to the more radical intracranial approach and sinus cranialization. Nevertheless, presence of complicating factors such as cerebrospinal fluid rhinorrhea, evidence of meningitis or the development of encephalomeningocoeles necessitated the standard protocol of sinus exploration and its cranialization or obliteration. Conclusion: Management protocols of Frontal Sinus injuries vary, based on aspects such as the timing of presentation and intervention, degree of injury sustained, concomitant associated Craniomaxillofacial injuries present, presence of complicating factors or Secondary/Residual deformities & Functional debility, and need to be decided upon on a case to case basis.
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Affiliation(s)
- Priya Jeyaraj
- Commanding Officer Military Dental Centre (Gough Lines), Secunderabad, Telangana, India
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12
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Glenn CA, Baker CM, Burks JD, Conner AK, Smitherman AD, Sughrue ME. Dural Closure in Confined Spaces of the Skull Base with Nonpenetrating Titanium Clips. Oper Neurosurg (Hagerstown) 2018; 14:375-385. [PMID: 28973649 DOI: 10.1093/ons/opx140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 07/06/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Dural repair in areas with limited operative maneuverability has long been a challenge in skull base surgery. Without adequate dural closure, postoperative complications, including cerebrospinal fluid (CSF) leak and infection, can occur. OBJECTIVE To show a novel method by which nonpenetrating, nonmagnetic titanium microclips can be used to repair dural defects in areas with limited operative access along the skull base. METHODS We reviewed 53 consecutive surgical patients in whom a dural repair technique utilizing titanium microclips was performed from 2013 to 2016 at our institution. The repairs primarily involved difficult-to-reach dural defects in which primary suturing was difficult or impractical. A detailed surgical technique is described in 3 selected cases involving the anterior, middle, and posterior fossae, respectively. An additional 5 cases are provided in more limited detail to demonstrate clip artifact on postoperative imaging. Rates of postoperative CSF leak and other complications are reported. RESULTS The microclip technique was performed successfully in 53 patients. The most common pathology in this cohort was skull base meningioma (32/53). Additional surgical indications included traumatic dural lacerations (9/53), nonmeningioma tumors (8/53), and other pathologies (4/53). The clip artifact present on postoperative imaging was minor and did not interfere with imaging interpretation. CSF leak occurred postoperatively in 3 (6%) patients. No obvious complications attributable to microclip usage were encountered. CONCLUSION In our experience, intracranial dural closure with nonpenetrating, nonmagnetic titanium microclips is a feasible adjunct to traditional methods of dural repair.
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Affiliation(s)
- Chad A Glenn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Cordell M Baker
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Joshua D Burks
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Andrew K Conner
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Adam D Smitherman
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Michael E Sughrue
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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13
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Some cool considerations of external lumbar drainage during its widespread application in neurosurgical practice: a long way to go. Chin Neurosurg J 2016. [DOI: 10.1186/s41016-016-0033-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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14
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Cha JH, Wee HJ, Seo JH, Ahn BJ, Park JH, Yang JM, Lee SW, Lee OH, Lee HJ, Gelman IH, Arai K, Lo EH, Kim KW. Prompt meningeal reconstruction mediated by oxygen-sensitive AKAP12 scaffolding protein after central nervous system injury. Nat Commun 2014; 5:4952. [PMID: 25229625 DOI: 10.1038/ncomms5952] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 08/11/2014] [Indexed: 11/09/2022] Open
Abstract
The meninges forms a critical epithelial barrier, which protects the central nervous system (CNS), and therefore its prompt reconstruction after CNS injury is essential for reducing neuronal damage. Meningeal cells migrate into the lesion site after undergoing an epithelial-mesenchymal transition (EMT) and repair the impaired meninges. However, the molecular mechanisms of meningeal EMT remain largely undefined. Here we show that TGF-β1 and retinoic acid (RA) released from the meninges, together with oxygen tension, could constitute the mechanism for rapid meningeal reconstruction. AKAP12 is an effector of this mechanism, and its expression in meningeal cells is regulated by integrated upstream signals composed of TGF-β1, RA and oxygen tension. Functionally, AKAP12 modulates meningeal EMT by regulating the TGF-β1-non-Smad-SNAI1 signalling pathway. Collectively, TGF-β1, RA and oxygen tension can modulate the dynamic change in AKAP12 expression, causing prompt meningeal reconstruction after CNS injury by regulating the transition between the epithelial and mesenchymal states of meningeal cells.
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Affiliation(s)
- Jong-Ho Cha
- SNU-Harvard NeuroVascular Protection Research Center, College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 151-742, Korea
| | - Hee-Jun Wee
- SNU-Harvard NeuroVascular Protection Research Center, College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 151-742, Korea
| | - Ji Hae Seo
- SNU-Harvard NeuroVascular Protection Research Center, College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 151-742, Korea
| | - Bum Ju Ahn
- SNU-Harvard NeuroVascular Protection Research Center, College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 151-742, Korea
| | - Ji-Hyeon Park
- SNU-Harvard NeuroVascular Protection Research Center, College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 151-742, Korea
| | - Jun-Mo Yang
- SNU-Harvard NeuroVascular Protection Research Center, College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 151-742, Korea
| | - Sae-Won Lee
- Department of Internal Medicine, Innovative Research Institute for Cell Therapy, Seoul National University Hospital, Seoul 110-799, Korea
| | - Ok-Hee Lee
- Department of Biomedical Science, CHA University, Seoul 135-081, Korea
| | - Hyo-Jong Lee
- College of Pharmacy, Inje University, Gimhae 621-749, Korea
| | - Irwin H Gelman
- Department of Cancer Genetics, Roswell Park Cancer Institute, Buffalo, New York 14263, USA
| | - Ken Arai
- Neuroprotection Research Laboratory, Departments of Radiology and Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02129, USA
| | - Eng H Lo
- Neuroprotection Research Laboratory, Departments of Radiology and Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02129, USA
| | - Kyu-Won Kim
- 1] SNU-Harvard NeuroVascular Protection Research Center, College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul 151-742, Korea [2] Department of Molecular Medicine and Biopharmaceutical Sciences, Graduate School of Convergence Science and Technology, and College of Medicine or College of Pharmacy, Seoul National University, Seoul 151-742, Korea
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15
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Tsang KKT, Whitfield PC. Traumatic brain injury: review of current management strategies. Br J Oral Maxillofac Surg 2011; 50:298-308. [PMID: 21530028 DOI: 10.1016/j.bjoms.2011.03.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Accepted: 03/17/2011] [Indexed: 11/26/2022]
Abstract
Head injury is a common condition with a high morbidity and mortality. Serious intracranial haematomas require early recognition and evacuation to maximise chances of independent outcomes. Recent organisational changes have promoted the development of trauma units and major trauma centres where patients can go through triage and be managed in an appropriate environment, and the development of management pathways in intensive treatment units has resulted in improvements in the outcome of traumatic brain injuries. Evidence for the treatment of cerebral perfusion pressure, and management of hyperventilation, osmotherapy, tracheostomy, and leakage of cerebrospinal fluid (CSF) has accumulated during the last decade and is important in the management of patients in all clinical settings. Since head injury is commonly associated with maxillofacial injuries, this review will be relevant to all who deal with this aspect of trauma.
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Affiliation(s)
- Kevin King-Tin Tsang
- Derriford Hospital, Department of Neurosurgery, Derriford Road, Plymouth PL6 8DH, United Kingdom.
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16
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Yadav JS, Mohindra S, Francis AA. CSF rhinorrhea-feasibility of conservative management in children. Int J Pediatr Otorhinolaryngol 2011; 75:186-9. [PMID: 21094534 DOI: 10.1016/j.ijporl.2010.10.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Accepted: 10/23/2010] [Indexed: 11/29/2022]
Abstract
PURPOSE To study the role of conservative management in CSF rhinorrhea in pediatric population. STUDY DESIGN A retrospective study in a tertiary care center. METHODS Cases with a diagnosis of CSF rhinorrhea discharged after conservative management but required skull base repair for recurrence of CSF rhinorrhea or meningitis were included in the study between periods 2000 and July 2010. RESULTS 12 cases of CSF rhinorrhea managed were treated conservatively, 7 patients again required rehospitalisation for recurrence of CSF rhinorrhea or meningitis. Male:female ratio was 4:1. The age ranged from 3 years to 14 years. Duration of recurrence of the CSF leak or meningitis varied from 6 to 121 months. Presenting symptoms included headache, rhinorrhea, or recurrent meningitis. The time from the initial injury to surgical exploration ranged from 163 to 3650 days. All patients were under regular follow-up and doing well except one had recurrence of the leak 2 months after surgery requiring revision surgery following which the patient had no recurrence. DISCUSSION The management of CSF fistulae is still a matter of debate and there will be a risk of recurrent meningitis on conservative management. Most comprehensive study to date indicates there is a 9.8% annual risk of developing meningitis. Duration of recurrence of the CSF leak or meningitis varied from 6 months to 121 months. The overall incidence of meningitis as a result of skull base defect and CSF leak ranges from 9% to 50% with a reported cumulative risk of 85% in 10 years if no repair is performed. As seen in our series CSF repair can resolve with conservative management but there is a risk of intermittent CSF leak or meningitis due to an incompletely healed or tenuous mucosal regeneration which should be addressed surgically. The patients with traumatic CSF leak who were treated with conservative management alone had a 25-29% risk of subsequent meningitis. CONCLUSION Conservative treatment of CSF leaks may lead to recurrent meningitis or leaks, therefore surgical closure of defects at the skull base should be considered treatment of choice to prevent ascending meningitis.
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Affiliation(s)
- Jagveer Singh Yadav
- Department of Otolaryngology and Head and Neck Surgery, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India.
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Hofmann E, Behr R, Schwager K. Imaging of Cerebrospinal Fluid Leaks*. Clin Neuroradiol 2009; 19:111-21. [DOI: 10.1007/s00062-009-9008-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Accepted: 04/07/2009] [Indexed: 10/20/2022]
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18
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Epidemiology, etiology, pathogenesis, and diagnosis of recurrent bacterial meningitis. Clin Microbiol Rev 2008; 21:519-37. [PMID: 18625686 DOI: 10.1128/cmr.00009-08] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Recurrent bacterial meningitis is a rare phenomenon and generally poses a considerable diagnostic challenge to the clinician. Ultimately, a structured approach and early diagnosis of any underlying pathology are crucial to prevent further episodes and improve the overall outcome for the affected individual. In this article, we are reviewing the existing literature on this topic over the last two decades, encompassing 363 cases of recurrent bacterial meningitis described in 144 publications. Of these cases, 214 (59%) were related to anatomical problems, 132 (36%) were related to immunodeficiencies, and 17 (5%) were related to parameningeal infections. The review includes a detailed discussion of the underlying pathologies and microbiological aspects as well as recommendations for appropriate diagnostic pathways for investigating this unusual entity.
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19
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De Paula Vernetta C, Ramírez Sabio JB, García Callejo J, Serrano Carañana MN, Marco Algarra J. Fístulas de líquido cefalorraquídeo en oído: a propósito de 5 casos. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2005; 56:273-9. [PMID: 15999794 DOI: 10.1016/s0001-6519(05)78613-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
CSF leaks in the ear are the result of an abnormal communication between subarachnoid and tympano mastoid areas, most of then as a result of trauma (90%). They mean a lisk of meningitis (4-50%) directly related to the etiology. Our aim is to present the CSF leak cases seen in our hospital in the last 2 years and a revision of their management. The main factor for a sucessful surgical repair is to use a multilayer tecnhique with a sucess rate close to 100%.
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Affiliation(s)
- C De Paula Vernetta
- Servicio de Otorrinolaringología, Hospital Clínico Universitario de Valencia.
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20
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Eftekhar B, Ghodsi M, Nejat F, Ketabchi E, Esmaeeli B. Prophylactic administration of ceftriaxone for the prevention of meningitis after traumatic pneumocephalus: results of a clinical trial. J Neurosurg 2004; 101:757-61. [PMID: 15540912 DOI: 10.3171/jns.2004.101.5.0757] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The purpose of this study was to compare the efficacy of the prophylactic use of ceftriaxone for the prevention of meningitis in patients with acute traumatic pneumocephalus. METHODS In this prospective, single-institution, randomized clinical trial, 109 patients with mild head injury and traumatic pneumocephalus were randomly assigned to receive or not receive an antibiotic medication (ceftriaxone, 1 g given twice a day) until occurrence of meningitis or at least 5 days after trauma. The patients were followed up for 1 month posttrauma. The 109 patients were divided into two groups: 53 were assigned to the prophylactic antibiotics therapy group and 56 to the control group. The overall rate of meningitis was 20.1% and the rates of meningitis in the two groups were not significantly different. The results were the same when adjusted for the patient's Glasgow Coma Scale score, sex, and age, as well as for an intradural location of air, air volume, presence of cerebrospinal fluid (CSF) rhinorrhea or CSF otorrhea, radiological sign of a skull base fracture, or intracranial hemorrhage. CONCLUSIONS The results of this study do not substantiate the efficacy of ceftriaxone used in the prevention of meningitis in patients with traumatic pneumocephalus after mild head injury or in any specific subgroup of these patients. Cerebrospinal fluid rhinorrhea and intracranial hemorrhage may be considered primary risk factors for the development of meningitis in patients with posttraumatic pneumocephalus and, in the absence of these symptoms, intradural location of air and air volume greater than 10 ml may be considered secondary risk factors. Further studies in this area are warranted.
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Affiliation(s)
- Behzad Eftekhar
- Department of Neurosurgery, Sina Hospital, Tehran University, Iran.
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