INDEX

    Basilar Skull Fracture

    Neurological, Trauma

    Last Updated Apr 30, 2017
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    Context

    • Classic clinical exam findings should be considered a positive diagnosis
    • High blunt force – 50% have another intracranial injury; 5-15% have C spine fracture
    • Complications relatively rare but commonly missed
    • associated with significant morbidity/mortality
    • CT scan is positive in only ~50% cases (still the gold standard though)
    • Adverse outcomes more common when CT positive
    • Complications:
      • CSF leak
      • Hearing loss
      • Cranial nerve palsy (entrapment > transection)
      • Cerebrovascular injury (Carotid > Vertebral)
      • Intracranial hemorrhage
    • Pitfalls:
      • Delayed development of clinical signs of complications (CSF leak, cranial nerve deficit, complications of carotid/vertebral artery injury routinely present later than 48 hours)
      • Intracranial hemorrhage may develop/evolve over 12-24 hours
      • Meningitis may further complicate CSF leak in up ~6%
      • Carotid artery injury poorly correlated with presence of involvement of carotid canal
      • Missed carotid artery injury associated with severe permanent neurologic deficit or mortality in up to 50%

    Recommended Treatment

    • No role for prophylactic antibiotics in CSF leak (Cochrane Review 2015)
    • Patients with CSF leak should be followed up at 7 days to ensure resolution
    • Suggest CT angiogram to check for cerebrovascular injury if:

    a. CT evidence of basal skull fracture involving carotid canal OR

    b. CT evidence of any basilar skull fracture AND:

    i. Middle cranial fossa involvement (temporal/sphenoid bone)

    ii. Any associated intracranial hemorrhage

    iii. Pneumocephalus or sphenoid sinus air fluid level

    c. Clinical or CT evidence of basilar skull fracture AND high-risk clinical features:

    i. High force mechanism

    ii. GCS < 6, Diffuse axonal injury

    iii. Focal neurologic deficits, visual changes

    Criteria For Hospital Admission

    • Altered LOC
    • Presence of non-surgical ICH or high-risk features (eg. high force, altered GCS/DAI, posterior fossa involvement, suspicion of vascular injury) requiring close observation/repeat/further imaging
    • Cerebrovascular injury requiring observation/further management
    • Factors preventing safe observation/discharge planning/adequate follow-up
    • Suspicion of meningitis in context of known/suspected CSF leak

    Criteria for Transfer to Neurosurgical Facility

    • Surgical or high-risk ICH requiring Neurosurgical intervention
    • Need for further imaging (CT scan, CT angiogram)
    • Need for management or further assessment for complications:
      • Cerebrovascular injury
      • Suspected cranial nerve entrapment or transection
      • CSF leak (especially if failed to resolve at 7 days)

    Criteria For Close Observation And/or Consult

    • CSF leak (consider consult to establish follow-up pathway)
    • Cranial nerve deficit (consult to establish follow-up pathway)
    • Proven or suspected cerebrovascular injury
    • Non-surgical ICH (high-risk to establish need for transfer/admit/observe/repeat imaging)
    • High-risk mechanism or involvement of middle or posterior cranial fossa (observe for 12-24 hours for delayed ICH)

    Criteria For Safe Discharge Home

    • Patient adequately assessed/imaged:
      • CT/CT angiogram
      • Cranial nerve examination including visual acuity
      • C spine
    • Clear return instructions for signs/symptoms of:
      • Intracranial hemorrhage
      • Visual change/loss
      • Cranial nerve deficit
      • CSF leak AND/OR signs/symptoms of meningitis
    • Establishment of specialist follow-up for presence of CSF leak or cranial nerve deficit at time of discharge
    • EP or GP reassessment at 7 days for reassessment for development of cranial nerve deficit, new or persistent CSF leak, signs/symptoms of cerebrovascular injury

    Quality Of Evidence?

    Justification

    Low to very low-level evidence for Admission/Transfer/Observation/Followup criteria – no established guidelines or large studies

    Low

    Antibiotic prophylaxis in CSF leak = Medium (Cochrane systematic review showed trend toward benefit but confidence interval crosses 1  –  likely more studies required). No current evidence to support.

    Moderate

    Canadian CT head rule provides high-level evidence as to when to consider CT head in blunt head trauma.

    High

    Low-level evidence for CT angiogram criteria

    Low

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