The aim of this study was to investigate if the anterior interhemispheric approach aia could be a safe and effective alternative approach to tumorous and nontumorous lesions of the anterior skull base. A basilar skull fracture is a break of a bone in the base of the skull. Complications of skull base fractures such as intracranial vascular injuries, nerve injuries, leptomeningeal cyst formation, cerebrospinal fluid fistulas, craniocervical instability. Orbitorrhea is an exceptional and lifethreatening condition which should be promptly managed. Surgical anatomy n the bony architecture of the skull base can be divided into three depressions. Bifrontal craniotomy an overview sciencedirect topics. It explains the features and options of the ao cmf classification system the case examples are grouped according to the tutorial papers, which account for the anatomical regionssubregions and the three precision levels. Occipital condyle fractures are often visualized on routine head ct images and are classified into three types. Penetrating anterior skull base fracture inflicted by a cows. In contrast to these effects of lowimpact trauma, higher forces will lead to anterior skull base fractures, which include the optic canal and will clearly affect the optic nerve. Because fractures do not respect the anatomic borders of the cranial fossa, another way to consider the skull base when evaluating the results of trauma, particularly skull base fractures, is to divide the skull base into four parts. Avulsion fracture chalkstick fracture greenstick fracture open fracture pathologic fracture tracture fracture. Anterior skull base surgery center nyu langone health.
Anterior compartment of the skull base anterior cranial fossa, which contains the eye sockets and sinuses. Cranial base fractures still represent a challenging issue. The anterior interhemispheric approach a safe and effective. They may occur in isolation or often in continuity with skull vault fractures or facial fractures. Mar 17, 2020 the bones which form the skull base are anterior, central, posterior 1. Pneumocephalus should raise the suspicion for a basilar skull fracture. They occur in 24% of head injuries and are often related to brain injury in 50% of the. Anterior skull base fractures are relatively common traumas but surgical indications are still discussed subcranial approach seemed successful in the management of all frontobasilar fractures with reasonably low complication rate 1. It is usually related to anterior skull base trauma. Access to anterior skull base via lefort i approach. Hasis basilar skull fractures, usually caused by substantial blunt force trauma, involve at least one of the bones that compose the base of the skull. It is separated from the central skull base by the tuberculum sellae and the dorsal margins of the. Missile injuries of the anterior skull base usually occur during war or warlike situations.
We screened the operative records of all patients with an anterior skull base lesion undergoing transcranial surgery. Thecsffistula ofthe lateral skull base was revealed by detection of fluorescein around the opening ofthe right eustachian tube at the fluorescein endoscopyperformedas postoperative followup 6 weeksaftertheduraplasty ofthe anterior skull base. It is divided into anterior, central, and posterior regions, which form the floor of the anterior, middle, and posterior cranial fossae. Although in some cases, there were also nasal, maxillary, temporal, zygomatic, and frontal bone fractures, the only type of fracture that. What is basal skull fracture basal skull fracture type of skull fracture which occurs in the floor of the skull that is around the eyes, ears, nose or back near the spine ellis, 2015 fracture of the base of the skull specifically involves the temporal bone, occipital bone, sphenoid bone, andor ethmoid bone wikipedia, 2016 morgan, b. Endoscopic surgery for any type of skull base defect is the gold standard. Given the comminution and medial and lateral anterior skull base involvement, this is a type iii frontobasal fracture. In contrast to anterior fossa floor and petrous temporal skull base fractures, wherein the site of impact may be remote from the fracture site, fractures of the suboccipital bone generally arise at the site of direct impact. Chapman introduction the skull base is traditionally divided into anterior, central, and posterior zones based principally on the appearance of the skull base as viewed from above fig. Meningitis is a complication in about 14% of cases.
Jan 11, 2020 a basilar skull fracture is a break of a bone in the base of the skull. The skull base is defined with its endocranial inner surface, which constitutes the floor of the cranial cavity, on which the brain rests, and its exocranial external surface fig. Anterior vs posterior oblique central skull base fracture central skull base fractures. The surgery of skull base fracture aims for restoration the normal anatomy, reconstruction of the skull base, to avoid complications i.
The structure of existing open skull base surgery cpt codes differs from other surgical codes which typically describe the incisionapproach, repair or resection of the. Orbitorrhea is defined as a leak of cerebrospinal fluid from a cranioorbital fistula. Craniofacial custom implants following oncologic surgery of anterior skull base tumors letter to the editor bilateral nonarteritic anterior ischemic optic neuropathy naaion. Clinical presentation since skull base fractures are the results of high force impacts and are often associated with other intracranial injuries. Certain tumors and conditions tend to occur in specific areas of the skull base. Skull base fracture an overview sciencedirect topics. The size of the defects does not seem to play a significant role in the. As described, existing skull base codes circa1994 are used for resection or excision of neoplastic e. This approach significantly improves vulzton of th ntrl kull b and also the nfrtmorl fo when th otror wall. Skull fractures may be linear or comminuted with multiple fracture lines, may be located on the cranial vault or in the basilar skull, may have a varying degree of depression or elevation, and can be open or closed.
Anterior skull base fractures are relatively common traumas but surgical indications are still discussed. In this article, the description, classification, incidence, clinical findings, and diagnosis of skull base fractures are outlined. The posterior central skull base p csb includes the clivus reaching the anterior margin of the great occipital foramen. Contrecoup fractures of the anterior cranial fossae as a. Pooling of blood surrounding the eyes is most commonly associated with fractures of the anterior.
Primary tumors of this area may be derived from the bone, paranasal sinuses, nasopharynx, dura, cranial nerves. A skull fracture is a break in one or more of the eight bones that form the cranial portion of the skull, usually occurring as a result of blunt force trauma. Jul 07, 2017 what is basal skull fracture basal skull fracture type of skull fracture which occurs in the floor of the skull that is around the eyes, ears, nose or back near the spine ellis, 2015 fracture of the base of the skull specifically involves the temporal bone, occipital bone, sphenoid bone, andor ethmoid bone wikipedia, 2016 morgan, b. Anterior cranial fossa fractures, particularly comminuted and oblique frontobasal fractures, are. This is generally a dangerous type of fracture as it very difficult to detect this type of fracture with the help of ct scans. The skull base is made up of 7 bones, the paired frontal and temporal bones, and the unpaired ethmoid, sphenoid, and occipital bones. Introduction the implementation of the shoulder harness seat belt in motor vehicles. Penetrating anterior skull base fracture inflicted by a.
Symptoms may include bruising behind the ears, bruising around the eyes, or blood behind the ear drum. Diagnosis and treatment of cerebrospinal fluid rhinorrhea. In an autopsy study, this region was injured in 82% of the cases. Skull baserelated lesions at routine head ct from the. Skull baserelated pathologic entities, often depicted on the first or last images of a routine head ct study, can be easily overlooked in the emergency setting if not incorporated in the interpreting radiologists search pattern, as the findings can be incompletely. A multidisciplinary approach and the contribution of different specialists is mandatory. As a result, the clinical signs and symptoms of skull base fractures may not be recognized immediately.
Resident manual of trauma to the face, head, and neck. Cerebrospinal fluid csf leak was observed in 16 patients 15%. Clinical signs of skull base fracture include anosmia, bilateral periorbital ecchymosis, hemotympanum andor perforation of the tympanic membrane, facial palsy, hearing loss, nystagmus, vertigo, cerebrospinal fluid csf rhinorrhea or otorrhea, and ecchymosis over the mastoid prominence, also known as a battle sign. Their importance is both as a marker of the severity of trauma and because they are, depending on location, associated with a variety of soft tissue injuries. If the force of the impact is excessive, the bone may fracture at or near the site of the impact and cause damage to the underlying structures within the skull such as the membranes, blood vessels, and brain. Contrecoup fractures of the base of the skull are regarded as rare in the clinical literature. So in patients presenting themselves after frontal impact it is important to be aware of the risk of vision loss and optic canal involvement.
In contrast, those groups that suffer multiple or large fractures and a broad or multifocal injury, as well as those that are victims of penetrating injury with significant comminuting fractures of the skull base, represent the most difficult groups to treat. There is still a controversy regarding the correct approach to these trauma due to the diversity of opinions as well as surgical approaches and timing. Transverse or oblique fractures, similar to other transverse central skull base fractures, are caused by a lateral or crushing injury, and are commonly associated with cranial nerve and internal carotid artery ica injury fig. Anterior cranial fossa fractures, particularly comminuted and oblique frontobasal fractures, are commonly associated with csf leak, either acute or delayed in presentation. Conversely, longitudinal clival fractures are more complex. Generally, the direction of a fracture will be in line with the direction of impact i. Types of skull base tumors and conditions johns hopkins. Key points skull base fractures are managed based on associated intracranial injury and complications, including vascular and cranial nerve injury and cerebrospinal fluid csf leak. A bifrontal craniotomy can be used for pathology in the anterior skull base, those that extend into the nasal cavity, and those that extend back to the suprasellar region. Skull base fractures are often associated with cranial vault or midface fractures. Extensive traumatic anterior skull base fractures with. The relationships between the impact site on the head, form of fracture at the point of impact with involvement of the skull cap andor the base of the skull, coup and contrecoup injuries of the brain, localization of contrecoup fractures in the anterior cranial fossa and the occurrence of monocle and spectacle haematomas display a major. Transsphenoidal approaches can be performed sublabially, transnasally, or completely endoscopically.
A posterior fossa fracture refers to the fracture that occurs in the basal part of the skull. In our material n171 falls on the same level and on or from stairs, the overall frequency of contrecoup fractures of the anterior cranial fossa in fatal craniocerebral trauma due to falls was 12%, as compared to 24% with occipital point of impact of the head. The petroccipital fissure forms the anterior lateral margin of the clivus, while the synchondrosis between the basioccipital and exoccipital bones forms the posterior lateral margins. We report 23 such cases managed during military conflicts and peacekeeping operations. Blindness was recognised at hospital admission, and decompression surgery was performed. A cerebrospinal fluid csf leak occurs in about 20% of cases and can result in fluid leaking from the nose or ear. We report a case of foreign body presence in the ethmoid sinus cavity with anterior skull base fracture and visual loss. Penetrating anterior skull base fracture inflicted by a cows horn adomas bunevicius, karolis bareikis, laimutis kalasauskas, and arimantas tamasauskas department of neurosurgery, hospital of lithuanian university of health sciences kaunas clinics, kaunas, lithuania. The anatomic definition of anterior, middle, and posterior skull base is used. Two weeks after trauma, no recurrence of vision had occurred. The bones which form the skull base are anterior, central, posterior 1. The anterior skull base is formed in the midline from the ethmoid roofand the planum sphenoidale of the sphenoid bone, while the paired inferior frontal bones and the lesser wings of the sphenoid lie more laterally.
Skull base trauma disclosures educational symposia. Skull fractures treatment algorithm bmj best practice. Axial ct image demonstrating a comminuted and displaced transversely oriented anterior skull base fracture arrows extending across the orbital roofs and ethmoid roofs, with involvement of the lateral orbital walls. Basilar fractures of the skull, also known as base of skull fractures, are a common form of skull fracture, particularly in the setting of severe traumatic head injury, and involve the base of the skull. An electronic fracture case collection complements the tutorial papers. A 42yearold male had an uncertain history of trauma and a penetrating wound near the left medial canthus. Falls backward from standing and assaults are the most common mechanisms of injury. A variety of histologic tumor types are present in the anterior skull base. We observed temporal fractures in 30% of these patients, occipital fractures in 20%, pyramidal fractures in 19%, anterior skull base fractures in 17%, and multiple fractures in 14%.
Central skull base the anterior central skull base a csb covers the upper nasal cavity and the sphenoid sinus. Basilar skull fractures are defined as linear fractures in the skull base, and are usually a part of multitude of facial fractures that extend to the skull base. Gross anatomy the base of the skull is a bony diaphragm composed of a number of bones from anterior. Anterior skull base fractures include a significant number of injuries resulting in rhinorrhea from a csf fistula. We herein report the case of a right posttraumatic orbitorrhea following anterior skull base trauma. Pdf mini craniotomy for anterior skull base lesions. Skull base fractures and their complications radiology key. Injuries in survivors are usually from a lowenergy missile and caused by trauma from direct contact through the missile trajectory.
Late manifestations traumatic lesions of the anterior. The three main regions of the skull base and the tumors and conditions that occur there most commonly are. The base of the skull or skull base forms the floor of the cranial cavity and separates the brain from the structures of the neck and face. A 73yearold man sustained blunt frontal trauma from a bicycle accident leading to a comminuted anterior skull base fracture involving the optic canal. Jul 08, 2019 routine noncontrast materialenhanced head ct is one of the most frequently ordered studies in the emergency department. They were not intended for use to address other skull base conditions such as traumatic injuries e. After the skull base is identified in the posterior ethmoids, a 30degree angled endoscope allows for dissection to be continued along the skull base from posterior to anterior in a retrograde fashion. The anterior skull base is the most common region of the skull base injured by a cranial missile.
Jan 22, 2015 the clivus is that part of the skull base situated between the foramen magnum and the dorsum sellae. It is separated from the central skull base by the tuberculum sellae and the dorsal margins of the lesser wings of sphenoid. Basis cranii fracture pdf skull base fractures are of high importance in neurotrauma. Skull fractures are common in the setting of both closed traumatic brain injury and penetrating brain injury. Complex anterior skullbase fracture caused by a bottle cap. Cvj fracture can occur in four major elements of its anatomic organization. Subcranial approach seemed successful in the management of all frontobasilar fractures with reasonably low complication rate 1. This approach supports the general delineation of the intracranial compartment into the anterior, middle, and posterior fossae. Basilar skull fractures are a common cause of death in many motor racing accidents. The most common sites of csf rhinorrhea following accidental trauma are the sphenoid sinus 30%, frontal. The anterior skull base surgery center team includes neurosurgeons as well as otolaryngologists, also known as ear, nose, and throat specialists, who are experienced in both open craniotomy and endoscopic endonasal surgery. Base of skull fracture radiology reference article. Anterior table fractures fractures of the anterior table of the frontal sinus vary from minimally displaced to severely displacedcomminuted depending upon the severity of the trauma and size of the sinus.
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