Skull Base Fractures with Basal Liquorrhea in an Acute Period of Severe Craniocerebral Trauma: A Clinical Picture, Diagnosis, Treatment Tactics and Prognosis

A.A. Potapov, A.G.Gavrilov, A.D. Kravchuk, N.V. Arutyunov, D.N. Kapitanov, V.G. Amcheslavsky, A.L. Parfenov

(Burdenko Research Institute of Neurosurgery, Moscow)

The study goal was to describe typical craniocerebral injuries, to determine indications for operation and its time in basal liquorrhea, developing in an acute period of craniocerebral trauma (CCT), and to assess prognosis in basal liquorrhea.

Materials and Methods. Retrospective analysis of the data base on craniocerebral trauma was carried out. There were 492 cases with acute severe CCT (Glasgow Coma score of less than 9), treated in the Burdenko Research Institute of Neurosurgery in 1986-2001. CCT outcomes were estimated on the basis of Glasgow Coma Scale 6 months after trauma. There were 385 males (78.7%) and 104 females (21.3%). Mean age and mean score (Glasgow Coma Scale) were 36.2±0.47 years and 6.1±0.1 respectively. Mean duration of coma was 8.4±0.4 days. Isolated and associated CCT were watched in 276 (56.1%) and 216 (43.9%) of cases respectively. Fractures of the skull base were diagnosed on the basis of evident X-ray signs, data of craniography or CT or presence of basal liquorrhea. All the patients were divided into three groups, dependent on presence of a skull base fracture or basal liquorrhea. Their distribution was as follows: the first group – cases without skull base fractures (230, 46.7%), the second group – cases with skull base fractures, having no basal liquorrhea (149, 30.3%), the third group – cases with skull base fractures and basal liquorrhea (113, 23.0%).

A Clinical Picture and Diagnosis. These groups had no reliable difference in such indices, as mean age, mean score according to Glasgow Coma Scale, coma duration and a number of patients with associated trauma.

Main Types of Skull, Brain and Meninges Injuries

Diffuse brain injuries, as a leading intracranial pathology, were more frequent in the group without skull base fractures (p<0.001). Focal injuries were more spread in the group with skull base fractures (p<0.001). SAH was more typical of cases with skull base fractures as well (p<0.001). Analyzing cases with skull base fractures, we failed to reveal any reliable difference in a rate of diffuse or focal injuries in the groups with and without basal liquorrhea.

Craniofacial trauma was more frequent in skull base fractures (9%), especially those, associated with basal liquorrhea (15%); the same index in cases without skull base fractures was 7% (p<0.05).

Intracranial pressure (ICP) was measured in 48 cases. Intracranial hypertension of 25 mm Hg and more was diagnosed in 22 patents (46%). Mean ICP was 24.0±1.8 mm Hg. Monitoring of ICP was carried out in 18 cases without skull base fractures, 7 cases with skull base fractures without basal liquorrhea and 23 patient with it. The lowest value of mean ICP was watched in the group with basal liquorrhea and cases without skull base fractures (21.2±2.2 mm Hg and 23.9±2.7 mm Hg respectively); this value in the group with skull base fractures without basal liquorrhea was 30.6±4.8 mm Hg (p<0.05).

Instrumental Diagnosis of Liquor Fistulas

Using different methods of examination, we managed to determine exact anatomical localization of liquor fistula in 101 cases (89.4%). Fistulas were located within the limits of one cranial fossa in 94 patients (93.1%). They were revealed in different cranial fossae in 7 cases (6.9%).

Fistulas were watched in the anterior cranial fossa in the majority of cases (61.7%); involvement of frontal sinuses was predominant (40.4%).

Treatment of Basal Liquorrhea. Treatment is carried out in accordance with the principles, adopted in the Burdenko Research Institute of Neurosurgery. Beginning with 1977, tactics of treatment has been based on Guidelines for the Management of the Severe Head Injury.

Conservative treatment resulted in a spontaneous closure of liquor fistulas in 95 cases (84.1%). Mean duration of liquorrhea in these patients was 13.9±2.9 days. The rest fistulas (18 cases, 15.9%) were closed during surgical interventions.

A spontaneous closure of fistulas, located in the area of the anterior skull base with involving the frontal sinus, was reliably less frequent in comparison with the same index in fistulas of other localization (p<0.01). When fistulas were localized on the border of frontal and ethmoidal sinuses, it was a reliable risk factor of long-term liquorrhea (p<0.05), demanding surgical intervention.

Revision of the skull base and closure of liquor fistulas were performed in 18 cases. Indications for an operation were as follows: ineffective conservative treatment, liquorrhea relapses, associated intracranial pathology (depressed fractures of cranial bones; contusion-crush foci within the brain; intracranial hematomas, demanding surgical removal; tense pneumocephalus).

Intracranial Pyo-Inflammatory Complications

Intracranial pyo-inflammatory complications were watched in 52 cases (10.6%). Their rate in skull base fractures and basal liquorrhea was reliably higher, than in skull base fractures without basal liquorrhea and in cases, having no fractures of this structure (18.6%, 10.1% and 7.0% respectively; p<0.001).

Risk factors, leading to development of meningitis in basal liquorrhea, were its duration (r=0.83, p<0.001), traumatic subarachnoid hemorrhage (r=0.68, p<0.001), artificial pulmonary ventilation (r=0.64, p<0.001) and a period of its carrying out (r=0.65, p<0.001). There were no correlations of this type in other groups.

There was insignificant correlation between accompanying somatic inflammatory complications (sepsis, pneumonia, uroinfection, bedsores) and intracranial pyo-inflammatory complications in cases with basal liquorrhea (r=0.3, p<0.001).

A number of cases with meningitis became greater in liquorrhea of more than 7 days. It increased sharply in liquorrhea, lasting more than 14 days (p<0.05).

Outcomes. Mortality in the group of cases without skull base fractures (10.45) was reliably lower, that in patients with skull base fractures (20.8%) and with basal liquorrhea (18.6%) (p<0.05). There was no reliable difference in distribution of favorable (good restoration and moderate invalidism) and unfavorable (severe disability and a vegetative state) outcomes. Comparison of cases without intracranial pyo-inflammatory complications demonstrated a smaller number of favorable outcomes in patients with skull base fractures without basal liquorrhea (40.2%). It was greater in groups without fractures (50.7%) and basal liquorrhea (47.1%) (p<0.05).

Conclusions.

1. Skull base fractures are a reliable risk factor, conditioning presence of contusion-crush foci, intracranial hematomas, SAH and worsening CCT outcomes.

2. Factors, promoting development of intracranial pyo-inflammatory complications in basal liquorrhea, include liquorrhea duration of more than 14 days, SAH, need of artificial pulmonary ventilation.

3. Outcomes are better in cases with severe CCT and skull base fractures, associated with basal liquorrhea, as compared to the analogous group without liquorrea.

4. When there are no contraindications for surgical treatment of basal liquorrhea, time of performing an operation should be determined with taking into account a period of a fistula’s spontaneous closure (13.9±2.9 days) and a growing risk of development of pyo-inflammatory complications.