Delayed Meningitis Complicated by the Frontal Sinus Opening to the Dura Mater in a Patient with Intracranial Injury Fifteen Years Ago / 대한신경손상학회지

Meningitis is the inflammation of the membranes of the brain and spinal cord. This disease is considered life threatening and classified as a medical and emergency. Here we report a case of delayed meningitis occurred in a patient with craniotomy for traumatic brain injury fifteen years ago. Meanwhile, he had been well, however he complained of headache for five days. A brain computed tomographic scan showed air density on the frontal lobe with frontal sinus defect and pansinusitis. His mental state was suddenly changed to stuporous, despite a day of empirical antibiotics. Therefore, a successful cranialization was performed and he was gradually improved. This is a rare case report. Our case shows that surgical intervention is to be considered in some cases of posttraumatic meningitis for effective and rapid control of infection.

Delayed Meningitis Complicated by the Frontal Sinus Opening to the Dura Mater in a Patient with Intracranial Injury Fifteen Years Ago / 대한신경손상학회지

Meningitis is the inflammation of the membranes of the brain and spinal cord. This disease is considered life threatening and classified as a medical and emergency. Here we report a case of delayed meningitis occurred in a patient with craniotomy for traumatic brain injury fifteen years ago. Meanwhile, he had been well, however he complained of headache for five days. A brain computed tomographic scan showed air density on the frontal lobe with frontal sinus defect and pansinusitis. His mental state was suddenly changed to stuporous, despite a day of empirical antibiotics. Therefore, a successful cranialization was performed and he was gradually improved. This is a rare case report. Our case shows that surgical intervention is to be considered in some cases of posttraumatic meningitis for effective and rapid control of infection.

Sixth and Twelfth Cranial Nerve Palsies Following Basal Skull Fracture Involving Clivus and Occipital Condyle

Oblique basal skull fractures resulting from lateral crushing injuries involving both clivus and occipital condyle are rare due to their deep locations. Furthermore, these fractures may present clinically with multiple cranial nerve injuries because neural exit routes are restricted in this intricate region. The authors present an interesting case of basal skull fractures involving the clivus and occipital condyle and presenting with sixth and contralateral twelfth cranial nerve deficits. Clinico-anatomic correlations and the courses of cranial nerve deficits are reiterated. To the authors' knowledge, no other report has been previously issued on concomitant sixth and contralateral twelfth cranial nerve palsies following closed head injury.

EMERGENCY BLEEDING CONTROL BY RAPID ENTIRE OROPHARYNGEAL PACKING IN A PATIENT WITH ACTIVE OROPHARYNGEAL BLEEDING FOLLOWING BASAL SKULL FRACTURE : REPORT OF A CASE

Transnasal Repair of Traumatic Cerebrospinal Fluid Rhinorrhea

OBJECTIVE: This study is aimed to evaluate the efficacy of transnasal repair of cerebrospinal fluid(CSF) rhinorrhea. METHODS: Thirteen patients with traumatic noniatrogenic CSF fistulas were included in the retrospective analysis. High-resolution thin-section computed tomographic cisternography was helpful in localization of the CSF leakage site. The most frequent leakage site was the sphenoid sinus. The transnasal approach(TNA), comprised of endonasal endoscopic surgery(EES) or transseptosphenoidal surgery(TSS), was mainly used for smaller fistulas. Total or selected ethmoidectomy depended on the localization of the leakage. Wide sphenoidotomy enabled detection and repair of CSF leaks from the sphenoid cavity. Three patients also underwent transcranial approach(TCA) because of the large or multi-fragmented bony defect and the need for further exposure for repair. Five patients developed ascending meningitis in the preoperative period with antibiotic prophylaxis. RESULTS: Twenty-five leaks were initially repaired using one of three techniques:EES alone in eight patients, EES plus TCA in three, and TSS alone in two. Ten patients who solely underwent the TNA did not experience the complications of the traditional TCA. One recurrent sphenoid fistula was successfully treated by TSS. After a follow-up from 12 to 88 months(mean 32.7), the overall success rate for 25 CSF fistulas was 100%. CONCLUSION: The transnasal repair is a safe, successful, and alternative approach for the surgical repair of traumatic CSF rhinorrhea, and also could be combined to TCA.

A Case of Traumatic Cerebral Infarction due to Injury of the Petrosal Internal Carotid Artery Resulting from Head Trauma

Deteriorated mental status and new neurological deficits after head trauma signify the formation of intracranial hematoma or brain edema. In a case of head trauma accompanied by basal skull fracture, even if without intracranial hematoma formation or edema, we should be alert to the possibility of injury of the petrosal carotid artery which needs prompt diagnostic evaluation and management. We report a case of traumatic cerebral infarction due to injury of the petrosal internal carotid artery and review the literatures.

Intracranial Infection in Head Injury

We analyzed 12 cases of intracranial infection retrospectively among 951 patients admitted for head injury in Kyungpook University Hospital during the last 7 years. Overall infection rate was 1.3%. Among 259 patients who had basal skull fracture, 6 cases(2.3%) were infected. Craniotomies were performed on 488 patients for various reasons. Among them 2 patients(0.4%) were infected due to the craniotomy. Ninety one patients had compound comminuted depressed skull fracture(FCCD). No one was infected due to FCCD. Two patients were infected after ventriculoperitoneal shunt to treat the posttraumatic hydrocephalus, and one case after burr hole trephination and drainage of intracerebral hematoma. The intracranial infection were as follows:7 cases of meningitis, 3 subdural or epidural empyema, one ventriculitis, and one brain abscess. In conclusion, basal skull fracture was the main cause of intracranial infection. As for craniotomy and FCCD, intracranial infection could be effectively prevented with appropriate management. Intracranial infection was a serious complication of the head injury prolonging hospital days and leading to sequelae.

Clinical Analysis of Basal Skull Fractures

The authors analysed 147 cases of basal skull fracture which were treated in the Department of Neurosurgery, Chungnam National University Hospital from January 1989 to December 1992. These fractures are difficult to diagnose by ordinary X-ray examination and are frequently inferred by clinical signs. The clinical features and radiological findings were reviewed. The results of the analysis are summarized as follows : 1) The basal skull fractures were more common in men than women-the ratio being 6 : 1. 2) In decreasing order of cause of basal skull fractures were traffic accidents(77%), fall down, assault and slipping. 3) The minor head injury, Glasgow Coma Scale Score(GCS) of 13 to 15, was 79 cases(54%), the moderate head injury 40 cases(27%) and the severe head injury 18 cases(19%). 4) In decreasing order of clinical features were otorrhea(71%) rhinorrhea(48%) and raccoon eye(33%) etc. 5) In decreasing order of the combined pathologies were skull fracture(55%), subdural hematoma(17%), epidural hematoma(16%) and intracerebral hematoma(12%) etc. 6) The facial nerve, vestibulo-cochlear nerve and optic nerve were the most commonly injured cranial nerve. 7) CSF leakage was noted in 139 cases and among them immediate type was far more common(96%) than the delayed type. 8) The incidence of meningitis was 5.4% and most of them associated with CSF leakage and the prophylatic antibiotic treatment has no effect to decrease infection rate. 9) In decreasing order of the frequency associated injuries were facial bone fracture(47%), clavicle fracture(19%), lower extremities fracture(9%) and upper extremities fracture(7%) etc.

Traumatic Intracranial Aneurysms

Five cases of traumatic intracranial aneurysm were presented. All of them were located at the cavernous segment of the internal carotid artery. These lesions were associated with basal skull fracture. Four cases were presented with massive epistaxis, and two of them required transfusion. All cases were treated successfully:four by detachable balloon occlusion of the proximal internal carotid artery and one by trapping of the lesion at the internal carotid artery. Because the mortality rate of ruptured traumatic aneurysm if high, clinical suspicion must be focused on prompt diagnostic work-up and early treatment.

A Clinical Study of 65 Cases in Basal Skull Fracture

65 consecutive patients with basal skull fracture admitted to Eul-Ji General Hospital, between March 1990 and March 1993 was carried out to study it's clinical and radiological presentations, complications, and outcomes. 1) Two thirds of the patients were between 20 and 40 years old and 82% were male. 2) 78% of the injuried were by traffic accidents and 17% were by fall down. 3) The outcomes of treatment were related to initial GCS(Glasgow coma scale) of the patients. 4) Clinical features were ear bleeding-54%, Racoon's eye-35%, hemotympaneum-32%, hearing loss-25%. 5) The combined lesions were skull fractures-43%, facial bone fractures-31%, subdural hematoma-19%, epidural hematoma-14%, and pneumocephalus-14%. 6) The combined cranial nerves injuried were facial nerve-32%, vestibulocochlear nerve-12%, oculomotor nerve-12%, abducens nerve-12%. 7) The location of basal skull fracture according to clinical feature and CT bone window were middle cranial fossa-54%, on anterior cranial fossa-22%, anterior and posterior cranial fossa-12%, posterior cranial fossa-2%. 8) Clinical features associated with types of petrous bone fractures were analyzed. 9) The time of onset and the degree of facial palsy had a influence on recovery of facial nerve function and the types of hearing loss had a role in recovery of hearing function. 10) CSF leakage were present in 16 cases and immediate type was more than delayed type. 11) Three patients(4.6%) developed meningitis, especially associated with CSF leakage and it's rate was higher when CSF leakage persisted over 1 week.

A traumatic Giant Intracavernous Aneurysm Associated with Fatal Epistaxis: A Case Report

The autors reported a giant aneurysm in the cavernous portion of the internal carotid artery which occurred after head trauma. The patient was a 24 year old man who had suffered massive epistaxis with hyoptension about 25 days after a traffic accident. On plain skull X-ray, there was evidence of a basal skull fracture and a linear fracture at the right frontotemporal area. The computed tomographic scan revealed round, well enhanced density in the sellar region. During a reattack of massive epistaxis, emergency carotid angiography showed a right cavernous-internal carotid artery aneurysm with a small extravasation of dye into the sphenoid sinus.