• 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%

• 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

• 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

• 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)

• 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)

• 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

1. Basilar Skull Fractures (St Paul’s EM Update 2018)

   
   

1. Ratilal et al. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. Cochrane Database of Systematic Reviews 2015: 4 (1-15)

   
   

2. Tunik et al. Clinical presentations and outcomes of children with basilar skull fractures after blunt head trauma. Annals of Emergency Medicine 2016, 68(4): 431-440

   
   

3. York et al. Association of internal carotid artery injury with carotid canal fractures in patients with head trauma. American Journal of Radiology 2005, 184:1672-1678

   
   

4. Das et. al. Maxillofacial trauma: managing potentially dangerous and disfiguring complex injuries. Emergency Medicine Practice. 2017, 19(4)

   
   

5. Heegaard et al. Skull fractures in adults. Up to Date. May 11, 2016