Introduction: Anterior skull base trauma (ASBT) is associated with complex fractures and intracranial hematomas (ICHs). The purpose of this study is to report on the Inkosi Albert Luthuli Central Hospital (IALCH) management algorithm and outcomes of this pattern of injury over a 13-year period.
Methods: We retrospectively reviewed the medical records of patients with diagnosis of ASBT admitted to the Department of Neurosurgery from January 2003 to December 2015. Data was analyzed for demographics, clinical presentation, mechanism of injury (MOI), neuro-radiology findings, management and outcomes.
Results: Two Hundred patients were recruited into the study, with a mean age of 28 ± 12 years, of which 175 (87.5%) were males. Focal neurological deficits (coeff. = -0.28, p < 0.001), associated injuries (coeff. = -0.30, p < 0.001), and neuroradiology findings (coeff. = -0.17, p = 0.02) showed negative correlations to discharge Glasgow Outcome Scale (GOS).
Mechanisms of injury were motor vehicle collisions [60, 30%], blunt assaults [51, 25.5%], low velocity penetrating injuries [41, 20.5%], gunshot injuries [36, 18%], and falls [12, 6%]. Ninety patients (45%) presented with early cerebrospinal fluid rhinorrhea, while it was delayed in 12 (6%) patients. Associated intracranial injuries included intra-cerebral [97,48.5%], acute subdural [22, 11%] and extra-dural hematomas [17, 8.5%]. Twenty-eight (14%) patients had associated facial bone fractures.
Anterior skull base repair was performed in 87 patients (43.5%); via craniotomy [85, 42.5%] and endoscopic transphenoidal approach [3, 1.5%]. Thirty-five (17.5 %) patients developed septic complications, which included meningitis [30, 15%] and intra-cerebral abscess [5, 2.5%]. Seven (3.5%) patients sustained vascular injuries. Admission Glasgow Coma Scale showed significant correlation to GOS on discharge (coeff. = 0.49, p < 0.001).The overall mortality rate was 9.5%.
Conclusions: ASBT is associated with significant morbidity, thus a multidisciplinary approach with standardized treatment protocols is crucial in improving outcomes.
Patient Care: The study will assist in development of standardized treatment protocols and thus crucial in improving outcomes:
1) Identifying particular clinical and neuro-radiological factors that would require early operative management which may improve patient outcomes.
2) Understand the scope of emerging technologies - Endoscopic Skull base repair in the management algorithm of ASBT
Learning Objectives: By the conclusion of the session, one should:
1) Understand the differences in outcomes of patients with ASBT based on mechanisms of injury, cerebrospinal spinal fluid rhinorrhea, pneumocephalus and neuro-radiology subtypes;
2) Identify those patients with ASBT that require early operative management via craniotomy as opposed to endoscopic skull base repairs;
3) Identify prognostic variables on admission to better prepare for effective patient management