Fractura de base de cráneo en recién nacidos: caso clínico / Basal fracture of the skull in a newborn: case report and review of the literature

Introduction: Reported incidence of cranial lesions in childbirth is about 1.7 to 59 per 10,000 births. Among these, fracture of the base of the skull is rare but serious due to sequelae and mortality. Objective: Describe a case of a newborn with a fracture of the temporal bone, review diagnosis and management of skull fractures. Clinical Case: The patient was born with assistance, use of forceps, showed deviation of the buccal commisure and otorrhagia on the left side during puerperium. CT Sean detected fracture of the base of the cranium at the level of the temporal bone. Hemogram, cultures and spinal fluid studies were done. Prophylactic therapy was initiated. All blood studies were negative and follow up studies were normal. Discussion: Literature reviews support the diagnosis to be confirmed through a CT sean, and an active search for meningitis be started through hemocultures, hemogram, and Cerebrospinal Fluid. Management should be conservative, evaluating the need for an LR Evidence shows that antibiotic prophylaxis for meningitis has little indication in these cases.

Introducción: La incidencia de lesiones de cráneo en recién nacidos reportadas son del orden de 1,7 a 59 por 10 000 nacimientos. Dentro de estas, las fracturas de base de cráneo son eventos poco frecuentes, pero de consideración dado su potencial gravedad en cuanto a mortalidad y secuelas. Objetivo: Relatar el caso de un recién nacido con una fractura de peñasco y revisar el diagnóstico y manejo de las lesiones de cráneo. Caso Clínico: El paciente, tras parto instrumentalizado por fórceps, presentó desviación de comisura bucal y otorragia durante su estadía en puerperio. La TAC de cerebro con reconstrucción ósea fue compatible con una fractura de base de cráneo (peñasco izquierdo). Se tomaron hemocultivo, hemograma y PCR y se inició antibioticoterapia profiláctica para meningitis. Evolucionó favorablemente con hemocultivos negativos, hemograma y PCR normales, TAC de control sin cambios y examen neurológico normal. Discusión: La literatura recomienda que el diagnóstico de fractura de base de cráneo debe ser confirmado por medio de TAC de cerebro y que debe realizarse una búsqueda activa de meningitis por medio de hemocultivos, hemograma y PCR, evaluar la necesidad de punción lumbar y manejar en forma conservadora. La evidencia señala que la profilaxis antibiótica para meningitis en estos pacientes no tiene indicación.

Frontobasal fractures: anatomical classification and clinical significance.

BACKGROUND: Frontobasal injury is a classic craniomaxillofacial fracture affecting the anterior cranial base. No data exist regarding the degree of frontobasal injury and associated midfacial fractures. The authors propose a classification of frontobasal and midface fractures involving the cranial base based on cadaveric experiments and comprehensive clinical experience. METHODS: An institutional review board-approved retrospective review was conducted on patients with frontobasal fractures from 1995 to 2005. Fractures were categorized by pattern, location, midfacial involvement (impure), and complications compiled. One hundred five cadaveric heads underwent blunt impact to the frontal bone and upper midface. Calvarial vault, cranial base, and midface fracture patterns were categorized. RESULTS: Three frontobasal fracture patterns were identified. Isolated linear cranial base fractures constitute type I. Vertical-linear fractures of the skull vault (frontal bone) occur in combination with base fractures, representing type II (vault and base). Comminution of the frontolateral skull vault and orbital roof in association with a linear base fracture constitute type III. Two hundred ninety patients were identified with 49 complications (cerebrospinal fistula, 24; and infectious 25). Type III (n = 159) had the highest complication rate (impure, 29 percent; pure, 17 percent), followed by type II (impure, 19 percent; pure, 5 percent). There is essentially no extension of midface fractures to the cranial vault. CONCLUSIONS: Frontobasal fractures have three unique and reproducible patterns based on vector, location, and force. This new classification scheme, paired with known patterns of midfacial injuries, assists in fully understanding frontofaciobasal injury and its complications. Overwhelmingly, impure type II and any type III fractures are associated with a high rate of complications and must be carefully managed.

Traumatic carotid cavernous fistula accompanying basilar skull fracture: a study on the incidence of traumatic carotid cavernous fistula in the patients with basilar skull fracture and the prognostic analysis about traumatic carotid cavernous fistula.

BACKGROUND: Traumatic carotid cavernous fistula (TCCF) is a rare vascular complication of traumatic brain and facial injury. The purpose of this study was to analyze the incidence of this disorder in different types of basilar skull fracture, determine whether particular clinical factors impacted outcomes, and discuss ways of improving prognosis. METHOD: We performed a retrospective analysis of cases with basilar skull fracture or angiography-confirmed TCCF in inpatients between 1999 and 2005, as well as an analysis of the incidence rate of TCCF in each type of basilar skull fracture. For patients diagnosed with TCCF, cases were divided into "disability" and "no disability" groups, and related clinical factors with potential impact on prognosis were analyzed. RESULTS: In 312 inpatients with basilar skull fractures, an overall incidence of 3.8% for TCCF was observed, and the incidence of this disorder with anterior fossa fracture, middle fossa fracture, and posterior fossa fracture was 2.4%, 8.3%, and 1.7%, respectively. In this retrospective analysis, factors such as patients' age, gender, number of embolization procedures performed, and time from injury to first symptom onset did not significantly affect outcome (p > 0.05). However, the time from first symptom onset to endovascular embolization differed significantly between the disability and no disability groups (p < 0.05). CONCLUSIONS: A relatively high incidence of TCCF occurred in patients with middle fossa fractures, especially those with transverse or oblique fractures. Prompt diagnosis and intervention should be emphasized in the management of patients with TCCF, and noninvasive techniques for early detection of TCCF should be considered in cases of middle fossa fractures under certain conditions after brain or facial trauma to ensure positive outcomes.

Nomenclature of frontobasal trauma: a new clinicoradiographic classification.

BACKGROUND: High-velocity accidents cause significant injury to the cranial and facial skeleton. Frontobasal fractures include fractures of the upper third of the face and anterior skull base. The pattern and classifications of these fractures are poorly understood at present. The authors have attempted a new comprehensive classification based on detailed clinicoradiographic evaluation. METHODS: A prospective study was undertaken in a tertiary care hospital in 1 calendar year (July of 2000 to June of 2001). All 63 patients with frontobasal fractures had detailed clinical and radiographic evaluation with plain radiographs and high-resolution computed tomographic scan. The fractures were classified as frontal, basal, and combined. Areas were separated as central (designated type 1) and lateral (designated type 2) to differentiate the pattern in the sagittal plane according to the site of impact. Combined fractures involving both central and lateral areas were designated type 3. These could be further classified into unilateral or bilateral or pure or impure, depending on the absence or presence of midfacial fractures. RESULTS: The fractures were subdivided into nine types considering the whole lateral and anteroposterior extents of the frontobasal region. The most common was the combined frontobasal type (30.16 percent). We found the pure type in 38.1 percent (24 of 63) and the impure type in 61.9 percent (39 of 63) of patients. Cerebrospinal fluid leaks occurred more commonly in impure types of frontobasal fracture. Blunt trauma leading to closed frontobasal fracture was seen in 35 patients. Penetrating trauma with open fractures was found in 28 patients and cerebrospinal fluid leak through the wound was seen in six of them. CONCLUSIONS: The new comprehensive classification clearly defines the anatomical areas within the frontobasal region, the nature of injury, and its association with midfacial injuries, and is helpful in planning the approach to their exposure in surgery.