![]() ![]() Persistent leaks require neurosurgical intervention. While prophylactic antibiotics are not indicated generally, use is still considered appropriate for coverage related to procedures such as insertion of intracranial pressure (ICP) monitor. However, patients with persistent leaks should have cerebrospinal fluid cultures to guide antibiotic therapy, and patients with clinical presentations consistent with meningitis should be treated with empiric antibiotics until culture results are available. A recent Cochrane review did not find sufficient evidence to recommend prophylactic antibiotics in patients with basilar skull fractures even in the presence of a documented cerebrospinal fluid leak. Patients with associated cerebrospinal fluid leaks, present in up to 45% of patients with basilar skull fractures, are often treated with prophylactic antibiotics to prevent meningitis, but there is no good evidence to support this practice. Surgical management is necessary for cases complicated by intracranial bleeding requiring decompression, vascular injury, significant cranial nerve injury, or persistent cerebrospinal fluid leak.īasilar skull fractures increase the risk of meningitis because of the increased possibility of bacteria from the paranasal sinuses, nasopharynx, and the ear canal making direct contact with the central nervous system. ![]() Otherwise, skull base fractures are often managed expectantly. Patients with intracranial hemorrhage require emergent neurosurgical evaluation. Those taking anticoagulants should be admitted to a facility with immediate neurosurgical capabilities and the ability to do frequent assessments of the neurologic decline, even if no hemorrhage is present on initial imaging. Patients with basilar skull fractures require admission for observation. In addition, nasal intermittent positive pressure ventilation (NIPPV) should be avoided as it may induce pneumocephalus. Nasogastric tubes and nasotracheal intubation should be avoided because of the risk for inadvertent intracranial tube placement. Associated cervical spine injury is common, so attention to cervical spine immobilization, particularly during airway management is necessary. A thorough trauma evaluation with interventions to stabilize airway, ventilation, and circulatory issues is the priority. ĬSF leak is not easy to diagnose and the fluid should be sent for analysis of beta transferrin.īasilar skull fractures are usually due to significant trauma. MRI may be useful in assessing nerve injury and in evaluating for a cerebrospinal fluid leak. Further imaging with CT angiography and venography (CTA, CTV) to assess for vascular injury should be considered in the acute setting. Pneumocephalus should raise the suspicion for a basilar skull fracture. Conversely, the detailed small neural and vascular channels visualized on MDCT may be misread as fractures. In patients where a high clinical suspicion for basilar skull fracture exists, multidetector CT (MDCT) thin-slice scanning through the face and skull base may aid in the detection of more subtle fractures. ![]() Unfortunately, skull-based fractures that are linear or non-displaced may be difficult to detect. The initial evaluation is usually via a non-contrast computed tomography (CT) scan. Plain x-rays are not sensitive to detect basilar skull fracture. ![]() Thin-cuts computed tomogram skull (less than 5 mm) bone window imaging is needed to identify such fractures in some cases of these cohorts.The diagnosis may be obvious on a physical exam in some cases. This sign is a reliable bedside clinical marker and is usually associated with anterior skull base fractures alongside the involvement of the frontal and the orbital bones. When a skull base fracture is present, the raccoon sign is present in 50 to 60% of such cases. Further extravasation of the blood beyond the periorbital region is limited owing to the orbital septum inserted into the tarsal plate. Classically, the tarsal plate will be spared in this condition. If it presents bilaterally, this finding is highly predictive of an anterior skull base fracture. This finding is not observed immediately following the injury and is typically delayed by 1 to 3 days. It is also referred to as the 'raccoon eyes' and the 'panda sign.' The pooling of blood around the eyes is most commonly associated with fractures of the base of the anterior cranial fossa. The 'Raccoon sign' comprises unilateral or bilateral progressive periorbital ecchymosis associated with edema. ![]()
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