A Comparative Analysis of Transcranial and Endoscopic Repair for Traumatic CSF Rhinorrhea.

BACKGROUND: Surgical treatment of anterior cranial base traumatic cerebrospinal fluid (CSF) rhinorrhea is challenging and is fraught with complications. Whether a person should be offered open craniotomy or endoscopic endonasal repair is a dilemma faced by most surgeons. This study is one of the few to directly compare the two forms of management. METHODS: Data were collected from two groups of 15 patients each who underwent transcranial CSF leak repair and endoscopic endonasal CSF leak repair in a tertiary care hospital over a 3-year period. Information including demographics, recurrence rates, complications, and hospital and intensive care unit (ICU) stay was recorded and analyzed. Outcome was assessed up to 6 months. RESULTS: Recurrence was seen in 9/30 patients, 6 in the transcranial group and 3 in the endoscopic group. Hospital stay was longer than 1 week in all the transcranially operated patients and only in 73% of the endoscopically operated patients (p = 0.439) although ICU stay was reduced in the endoscopic group (p = 0.066). Complications were more common with transcranial repair (seven of eight patients who underwent transcranial repair, p = 0.035) with anosmia being the most common (33.3%, p = 0.042). CONCLUSION: The transcranial open repair is a reasonable choice especially for leaks that occur through the frontal sinus and extend backward into the frontoethmoidal region. However, this approach has the drawbacks of greater number of complications, higher recurrence rate, and longer ICU and overall hospital stay. The endoscopic endonasal repair enjoys a lower morbidity profile although it may not be an adequate treatment for leaks that are placed far laterally in the frontal sinus.

Intracranial pressure monitoring in diffuse brain injury-why the developing world needs it more?

BACKGROUND: Use of ICP monitoring is considered to be part of "standard of care" in management of severe traumatic brain injury, but it is rarely used in developing countries. The authors present a study which evaluates the efficacy and outcomes of ICP monitoring at a high-volume trauma center in India. METHODS: Data on management and outcomes for 126 patients who were admitted with diffuse traumatic brain injury (GCS 3-8) were studied prospectively over an 18-month period. These patients were treated by one of the two specific protocols: ICP monitoring-based or non-ICP monitoring-based. The primary outcome was measured based on 2 weeks mortality and GOS-E at 1, 3, and 6 months. Secondary outcome was measured based on need for brain-specific treatment, length of ICU stay, and radiation exposure. RESULTS: Mortality in a subset of patients who underwent surgical intervention later due to increased ICP values, drop in GCS, or radiological deterioration was noted to be significantly lower in the ICP monitoring group (p = 0.03), in spite of statistically insignificant difference in overall mortality rates between groups. GOS-E scores at 1 month were significantly better (p = 0.033) in ICP monitoring group, even though they equalized at 3 and 6 months. The need for brain-specific treatment (p < 0.001), radiation exposure (p < 0.001), and length of ICU stay (p = 0.013) was significantly lower in the ICP monitoring group. CONCLUSIONS: ICP monitoring-based treatment protocol helps in achieving faster recovery; lowers mortality rates in operated patients; and reduces ICU stay, radiation exposure, and the need for brain-specific treatment.