Extensive traumatic anterior skull base fractures with cerebrospinal fluid leak: Classification and repair techniques using combined vascularized tissue flaps

Jacob B. Archer, Hai Sun, Phillip A. Bonney, Yan Daniel Zhao, Jared C. Hiebert, Jose A. Sanclement, Andrew S. Little, Michael E. Sughrue, Nicholas Theodore, Jeffrey James, Sam Safavi-Abbasi

Research output: Contribution to journalArticle

13 Citations (Scopus)

Abstract

Objective This article introduces a classification scheme for extensive traumatic anterior skull base fracture to help stratify surgical treatment options. The authors describe their multilayer repair technique for cerebrospinal fluid (CSF) leak resulting from extensive anterior skull base fracture using a combination of laterally pediculated temporalis fascial-pericranial, nasoseptal-pericranial, and anterior pericranial flaps. Methods Retrospective chart review identified patients treated surgically between January 2004 and May 2014 for anterior skull base fractures with CSF fistulas. All patients were treated with bifrontal craniotomy and received pedicled tissue flaps. Cases were classified according to the extent of fracture: Class I (frontal bone/sinus involvement only); Class II (extent of involvement to ethmoid cribriform plate); and Class III (extent of involvement to sphenoid bone/sinus). Surgical repair techniques were tailored to the types of fractures. Patients were assessed for CSF leak at follow-up. The Fisher exact test was applied to investigate whether the repair techniques were associated with persistent postoperative CSF leak. Results Forty-three patients were identified in this series. Thirty-seven (86%) were male. The patients' mean age was 33 years (range 11-79 years). The mean overall length of follow-up was 14 months (range 5-45 months). Six fractures were classified as Class I, 8 as Class II, and 29 as Class III. The anterior pericranial flap alone was used in 33 patients (77%). Multiple flaps were used in 10 patients (3 salvage) (28%)-1 with Class II and 9 with Class III fractures. Five (17%) of the 30 patients with Class II or III fractures who received only a single anterior pericranial flap had persistent CSF leak (p < 0.31). No CSF leak was found in patients who received multiple flaps. Although postoperative CSF leak occurred only in high-grade fractures with single anterior flap repair, this finding was not significant. Conclusion s Extensive anterior skull base fractures often require aggressive treatment to provide the greatest longterm functional and cosmetic benefits. Several vascularized tissue flaps can be used, either alone or in combination. Vascularized flaps are an ideal substrate for cranial base repair. Dual and triple flap techniques that combine the use of various anterior, lateral, and nasoseptal flaps allow for a comprehensive arsenal in multilayered skull base repair and salvage therapy for extensive and severe fractures.

Original languageEnglish (US)
Pages (from-to)647-656
Number of pages10
JournalJournal of neurosurgery
Volume124
Issue number3
DOIs
StatePublished - Mar 2016

Fingerprint

Skull Fractures
Skull Base
Sphenoid Bone
Ethmoid Bone
Frontal Bone
Sphenoid Sinus
Cerebrospinal Fluid Leak
Frontal Sinus
Salvage Therapy
Surgical Flaps
Craniotomy
Cosmetics
Fistula
Cerebrospinal Fluid

Keywords

  • Anterior skull base repair
  • Cerebrospinal fluid leak
  • Frontal sinus
  • Nasoseptal flap pericranial flap
  • Temporoparietal fascial flap
  • Traumatic meningitis

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

Extensive traumatic anterior skull base fractures with cerebrospinal fluid leak : Classification and repair techniques using combined vascularized tissue flaps. / Archer, Jacob B.; Sun, Hai; Bonney, Phillip A.; Zhao, Yan Daniel; Hiebert, Jared C.; Sanclement, Jose A.; Little, Andrew S.; Sughrue, Michael E.; Theodore, Nicholas; James, Jeffrey; Safavi-Abbasi, Sam.

In: Journal of neurosurgery, Vol. 124, No. 3, 03.2016, p. 647-656.

Research output: Contribution to journalArticle

Archer, JB, Sun, H, Bonney, PA, Zhao, YD, Hiebert, JC, Sanclement, JA, Little, AS, Sughrue, ME, Theodore, N, James, J & Safavi-Abbasi, S 2016, 'Extensive traumatic anterior skull base fractures with cerebrospinal fluid leak: Classification and repair techniques using combined vascularized tissue flaps', Journal of neurosurgery, vol. 124, no. 3, pp. 647-656. https://doi.org/10.3171/2015.4.JNS1528
Archer, Jacob B. ; Sun, Hai ; Bonney, Phillip A. ; Zhao, Yan Daniel ; Hiebert, Jared C. ; Sanclement, Jose A. ; Little, Andrew S. ; Sughrue, Michael E. ; Theodore, Nicholas ; James, Jeffrey ; Safavi-Abbasi, Sam. / Extensive traumatic anterior skull base fractures with cerebrospinal fluid leak : Classification and repair techniques using combined vascularized tissue flaps. In: Journal of neurosurgery. 2016 ; Vol. 124, No. 3. pp. 647-656.
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title = "Extensive traumatic anterior skull base fractures with cerebrospinal fluid leak: Classification and repair techniques using combined vascularized tissue flaps",
abstract = "Objective This article introduces a classification scheme for extensive traumatic anterior skull base fracture to help stratify surgical treatment options. The authors describe their multilayer repair technique for cerebrospinal fluid (CSF) leak resulting from extensive anterior skull base fracture using a combination of laterally pediculated temporalis fascial-pericranial, nasoseptal-pericranial, and anterior pericranial flaps. Methods Retrospective chart review identified patients treated surgically between January 2004 and May 2014 for anterior skull base fractures with CSF fistulas. All patients were treated with bifrontal craniotomy and received pedicled tissue flaps. Cases were classified according to the extent of fracture: Class I (frontal bone/sinus involvement only); Class II (extent of involvement to ethmoid cribriform plate); and Class III (extent of involvement to sphenoid bone/sinus). Surgical repair techniques were tailored to the types of fractures. Patients were assessed for CSF leak at follow-up. The Fisher exact test was applied to investigate whether the repair techniques were associated with persistent postoperative CSF leak. Results Forty-three patients were identified in this series. Thirty-seven (86{\%}) were male. The patients' mean age was 33 years (range 11-79 years). The mean overall length of follow-up was 14 months (range 5-45 months). Six fractures were classified as Class I, 8 as Class II, and 29 as Class III. The anterior pericranial flap alone was used in 33 patients (77{\%}). Multiple flaps were used in 10 patients (3 salvage) (28{\%})-1 with Class II and 9 with Class III fractures. Five (17{\%}) of the 30 patients with Class II or III fractures who received only a single anterior pericranial flap had persistent CSF leak (p < 0.31). No CSF leak was found in patients who received multiple flaps. Although postoperative CSF leak occurred only in high-grade fractures with single anterior flap repair, this finding was not significant. Conclusion s Extensive anterior skull base fractures often require aggressive treatment to provide the greatest longterm functional and cosmetic benefits. Several vascularized tissue flaps can be used, either alone or in combination. Vascularized flaps are an ideal substrate for cranial base repair. Dual and triple flap techniques that combine the use of various anterior, lateral, and nasoseptal flaps allow for a comprehensive arsenal in multilayered skull base repair and salvage therapy for extensive and severe fractures.",
keywords = "Anterior skull base repair, Cerebrospinal fluid leak, Frontal sinus, Nasoseptal flap pericranial flap, Temporoparietal fascial flap, Traumatic meningitis",
author = "Archer, {Jacob B.} and Hai Sun and Bonney, {Phillip A.} and Zhao, {Yan Daniel} and Hiebert, {Jared C.} and Sanclement, {Jose A.} and Little, {Andrew S.} and Sughrue, {Michael E.} and Nicholas Theodore and Jeffrey James and Sam Safavi-Abbasi",
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T1 - Extensive traumatic anterior skull base fractures with cerebrospinal fluid leak

T2 - Classification and repair techniques using combined vascularized tissue flaps

AU - Archer, Jacob B.

AU - Sun, Hai

AU - Bonney, Phillip A.

AU - Zhao, Yan Daniel

AU - Hiebert, Jared C.

AU - Sanclement, Jose A.

AU - Little, Andrew S.

AU - Sughrue, Michael E.

AU - Theodore, Nicholas

AU - James, Jeffrey

AU - Safavi-Abbasi, Sam

PY - 2016/3

Y1 - 2016/3

N2 - Objective This article introduces a classification scheme for extensive traumatic anterior skull base fracture to help stratify surgical treatment options. The authors describe their multilayer repair technique for cerebrospinal fluid (CSF) leak resulting from extensive anterior skull base fracture using a combination of laterally pediculated temporalis fascial-pericranial, nasoseptal-pericranial, and anterior pericranial flaps. Methods Retrospective chart review identified patients treated surgically between January 2004 and May 2014 for anterior skull base fractures with CSF fistulas. All patients were treated with bifrontal craniotomy and received pedicled tissue flaps. Cases were classified according to the extent of fracture: Class I (frontal bone/sinus involvement only); Class II (extent of involvement to ethmoid cribriform plate); and Class III (extent of involvement to sphenoid bone/sinus). Surgical repair techniques were tailored to the types of fractures. Patients were assessed for CSF leak at follow-up. The Fisher exact test was applied to investigate whether the repair techniques were associated with persistent postoperative CSF leak. Results Forty-three patients were identified in this series. Thirty-seven (86%) were male. The patients' mean age was 33 years (range 11-79 years). The mean overall length of follow-up was 14 months (range 5-45 months). Six fractures were classified as Class I, 8 as Class II, and 29 as Class III. The anterior pericranial flap alone was used in 33 patients (77%). Multiple flaps were used in 10 patients (3 salvage) (28%)-1 with Class II and 9 with Class III fractures. Five (17%) of the 30 patients with Class II or III fractures who received only a single anterior pericranial flap had persistent CSF leak (p < 0.31). No CSF leak was found in patients who received multiple flaps. Although postoperative CSF leak occurred only in high-grade fractures with single anterior flap repair, this finding was not significant. Conclusion s Extensive anterior skull base fractures often require aggressive treatment to provide the greatest longterm functional and cosmetic benefits. Several vascularized tissue flaps can be used, either alone or in combination. Vascularized flaps are an ideal substrate for cranial base repair. Dual and triple flap techniques that combine the use of various anterior, lateral, and nasoseptal flaps allow for a comprehensive arsenal in multilayered skull base repair and salvage therapy for extensive and severe fractures.

AB - Objective This article introduces a classification scheme for extensive traumatic anterior skull base fracture to help stratify surgical treatment options. The authors describe their multilayer repair technique for cerebrospinal fluid (CSF) leak resulting from extensive anterior skull base fracture using a combination of laterally pediculated temporalis fascial-pericranial, nasoseptal-pericranial, and anterior pericranial flaps. Methods Retrospective chart review identified patients treated surgically between January 2004 and May 2014 for anterior skull base fractures with CSF fistulas. All patients were treated with bifrontal craniotomy and received pedicled tissue flaps. Cases were classified according to the extent of fracture: Class I (frontal bone/sinus involvement only); Class II (extent of involvement to ethmoid cribriform plate); and Class III (extent of involvement to sphenoid bone/sinus). Surgical repair techniques were tailored to the types of fractures. Patients were assessed for CSF leak at follow-up. The Fisher exact test was applied to investigate whether the repair techniques were associated with persistent postoperative CSF leak. Results Forty-three patients were identified in this series. Thirty-seven (86%) were male. The patients' mean age was 33 years (range 11-79 years). The mean overall length of follow-up was 14 months (range 5-45 months). Six fractures were classified as Class I, 8 as Class II, and 29 as Class III. The anterior pericranial flap alone was used in 33 patients (77%). Multiple flaps were used in 10 patients (3 salvage) (28%)-1 with Class II and 9 with Class III fractures. Five (17%) of the 30 patients with Class II or III fractures who received only a single anterior pericranial flap had persistent CSF leak (p < 0.31). No CSF leak was found in patients who received multiple flaps. Although postoperative CSF leak occurred only in high-grade fractures with single anterior flap repair, this finding was not significant. Conclusion s Extensive anterior skull base fractures often require aggressive treatment to provide the greatest longterm functional and cosmetic benefits. Several vascularized tissue flaps can be used, either alone or in combination. Vascularized flaps are an ideal substrate for cranial base repair. Dual and triple flap techniques that combine the use of various anterior, lateral, and nasoseptal flaps allow for a comprehensive arsenal in multilayered skull base repair and salvage therapy for extensive and severe fractures.

KW - Anterior skull base repair

KW - Cerebrospinal fluid leak

KW - Frontal sinus

KW - Nasoseptal flap pericranial flap

KW - Temporoparietal fascial flap

KW - Traumatic meningitis

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