Prophylactic administration of ceftriaxone for the prevention of meningitis after traumatic pneumocephalus: results of a clinical trial

Clinical Significance of Pneumocephalus in Pediatric Mild Traumatic Brain Injury

OBJECTIVES

Mild traumatic brain injury (mTBI) comprises most (70%-90%) of all pediatric head trauma cases seeking emergency care. Although most mTBI cases have normal initial head computed tomography scan, a considerable portion of the cases have intracranial imaging abnormalities on computed tomography scan. Whereas other intracranial pathological findings have been extensively studied, little is known about the clinical significance of pneumocephalus in pediatric mTBI.

METHODS

We retrospectively identified pediatric mTBI patients with pneumocephalus using the institutional database of a large regional trauma referral center. Outcome measures were defined as clinically important TBI (ciTBI), hospitalization, intensive care unit (ICU) admission, and neurosurgical intervention. Comparisons were made between pneumocephalus and control (isolated linear fracture) groups as well as between isolated (only linear fracture and pneumocephalus) and nonisolated pneumocephalus (pneumocephalus and TBI) groups.

RESULTS

Among 3524 pediatric mTBI cases, 43 cases had pneumocephalus (1.2%). Twenty-one cases (48.8%) had isolated pneumocephalus. The pneumocephalus group had higher rates of ciTBI, hospital admission, ICU admission, and neurosurgery when compared with the isolated linear fracture (control) group. The isolated pneumocephalus group had fewer ciTBI (21.1% vs 70%, P = 0.002), fewer hospitalization (23.8% vs 81.8%, P < 0.001), but similar ICU admission rates (4.8% vs 22.7%, P = 0.089) and length of hospital stay (4.0 ± 2.7 vs 3.6 ± 2.4 days, P = 0.798) in comparison to the nonisolated pneumocephalus group. None of the patients in the isolated group had neurosurgery whereas 2 patients in the nonisolated pneumocephalus group underwent surgery. Multivariable analysis revealed pneumocephalus as an independent predictor of ciTBI and hospital admission, but not ICU admission or neurosurgical intervention.

CONCLUSION

Pneumocephalus is associated with increased rates of hospitalization and ciTBI, but not ICU admission, unfavorable outcome, or neurosurgical intervention in pediatric mTBI. Although usually spontaneously resolving pathology, it may occasionally be linked with complications such as cerebrospinal fluid leakage, meningitis, and tension pneumocephalus. Therefore, careful evaluation, close observation, and early detection of complications may prevent adverse outcomes.

Prophylactic Antibiotics in Patients with Traumatic Pneumocephalus or Cerebrospinal Fluid Leak

INTRODUCTION

Pneumocephalus and cerebrospinal fluid (CSF) leaks are uncommon after trauma, but they expose the sterile CSF to environmental pathogens and create theoretical risk of central nervous system infection (CNSI). Prophylactic antibiotics are commonly given to these patients, but there is a paucity of evidence to guide this practice. We aim to quantify the incidences of these entities and analyze the efficacy of prophylactic antibiotics in preventing CNSIs.

METHODS

A retrospective cohort study was conducted using our institutional trauma registry. All patients admitted from January 2014 to July 2020 with traumatic pneumocephalus (TP) or basilar skull fracture with CSF leak (BSF-CSF) were included. ICD-9 and ICD-10 codes were used to identify CNSIs. CNSI rates among defined prophylactic antibiotic regimens, no antibiotics, and other antibiotic regimens were evaluated. ANOVA was used to analyze differences between the groups.

RESULTS

365 patients met inclusion criteria: 360 with TP; 5 with BSF-CSF. 1.1% (4/365) of patients developed CNSI, all with isolated traumatic pneumocephalus. 1.4% of patients (1/72) without antibiotics; 1.2% (3/249) receiving IV antibiotics outside of a defined regimen; and 1.1% (1/88) on a designated prophylactic regimen developed CNSIs. ANOVA indicated the incidence of CNSI was not significantly different among patients who received antibiotics or not, regardless of the regimen (p-value 0.958).

CONCLUSION

TP and BSF-CSF are rare diagnoses among trauma patients. The rate of CNSI is marginal and antibiotics do not appear to confer a protective advantage. A larger trial is needed to elucidate the true effect of antibiotics on preventing CNSIs in patients with these uncommon diagnoses.

Relationship between T-cell-dependent and T-cell-independent vaccines after neurotrauma; is the B-cell response preserved?

Background

After trauma and central nervous system (CNS) injury, trauma-induced immune deficiency syndrome (TIDS) and CNS injury-induced immune deficiency syndrome (CIDS) may negatively affect responses to T-cell-dependent vaccines, such as pneumococcal conjugate vaccine (PCV) recommended after basilar fracture. This study (NCT02806284) aimed to investigate whether there after neurotrauma is a correlation between T-cell-dependent and independent vaccine responses and, thus, if B-cell activity is similarly depressed and whether the T-cell-dependent response is possible to predict.

Methods

Adult patients with basilar fracture (n = 33) and those undergoing pituitary gland surgery (n = 23) were within 10 days vaccinated with a T-cell-dependent vaccine against Haemophilus influenzae type b (Hib) and a T-cell-independent pneumococcal polysaccharide vaccine (PPSV). Samples reflecting the systemic inflammatory response and pre- and post-vaccination antibody levels after 3–6 weeks against Hib and PPSV were collected and determined by enzyme immunoassays.

Results

High and significant correlations were detected in the responses to different pneumococcal serotypes, but none between the Hib and PPSV responses. No differences in trauma scores, C-reactive protein, IL-6, IL-10, pentraxin 3, fractalkine or calprotectin plasma concentrations or in ex vivo TNF-α, IL-6 or IL-10 responses to endotoxin were found between Hib vaccination responders and non-responders.

Conclusions

There was no correlation between the pneumococcal responses and that to Hib, indicating that B-cell function is not similarly depressed as T-cell function. Grading of the trauma or parameters reflecting the innate immune response could not predict the T-cell-dependent vaccine response. There is a need of further studies evaluating the vaccine response after neurotrauma.

Management of cerebrospinal fluid leak: the importance of multidisciplinary approach

Cerebrospinal fluid (CSF) leak remains a rare condition, characterized by serious complications and potentially fatal. According to different etiologies, CSF leaks may be classified into two main categories: traumatic and spontaneous. Spontaneous fistulas seem to be mainly related to obesity and idiopathic intracranial hypertension. Diagnosis is both clinical and radiological. During the last three decades, surgical treatment has mostly shifted to endonasal endoscopic approach, which widely demonstrated to be more effective than invasive intracranial ones. Post-operative complications, long-term sequelae and hospital stay are strongly reduced thanks to endoscopic approach. The diagnosis and treatment of CSF leaks represent a difficult and challenge task. The main effort seems to be related to the precise localization of the leak. An accurate assessment of both predisposing factors and comorbidities is mandatory in case of spontaneous leaks. However, a clinical multidisciplinary evaluation as well as treatment, is essential to decrease the rate of failure of surgery. The presence of a dedicated instruments, the Skull Base Team, the knowledge of reconstructive materials and techniques represents a decisive result in therapeutical management even if for each patient an effective therapeutic algorithm can be obtained considering the correct leak detection and characteristics. In conclusion the strict teamwork with neurosurgeons, neuroradiologists, ophtalmologists will enable the development also of innovative biomaterials, which could spread and standardize multi-layer techniques, nowadays still related to surgeon preferences.

Pneumocephalus with meningitis secondary to an old traumatic anterior cranial fossa defect

We report a case of a 30-year-old man who presented with altered mental status, fever, headache and vomiting for 3 days. An initial CT scan of the brain revealed the presence of pneumocephalus with a bony defect in the anterior cranial fossa. The pneumocephalus was not explained initially and the patient was re-examined for any signs of trauma to the face, and a review of the history revealed a series of three traumatic events months prior to this illness. Further laboratory studies revealed Streptococcus pneumoniae in the blood and bacterial meningitis. He was treated with antibiotics and was later taken up for endoscopic repair of the skull base defect. This case highlights the importance of recognising post-traumatic pneumocephalus with superimposed meningitis and sepsis months after a traumatic event to the skull base.

Endoscopic Skull Base Repair Strategy for CSF Leaks Associated with Pneumocephalus

Background: Cerebrospinal (CSF) fluid leaks with associated pneumocephalus (PNC) represent a condition bearing serious risks for the patient, with little data available in the literature. Reported success rates of endoscopic skull base repair are lower when PNC is associated than in the case of simple CSF leaks. The present study represents an analysis of our experience with endoscopic management of this condition. Methods: Records of patients with pneumocephalus and associated CSF leaks, who underwent endoscopic skull base repair, were reviewed. Demographics, history, etiology of PNC, size of defect, surgical approach, reconstruction technique and complications were evaluated. Results: Twenty patients with CSF leaks and PNC underwent endonasal repair by the senior author between 2005 and 2019. Defect size was larger than 15 mm in all cases. All patients presented either worsening of PNC under conservative treatment or tension PNC. First-attempt closure of the defect was successful in all patients (100%), with resolution of the pneumocephalus. One patient developed a synechia in the proximity of the frontal ostium, as a postoperative complication. The mean follow-up was 39 months (range: 15–94 months). Conclusion: The present study represents a proposed argument for earlier endoscopic endonasal treatment in patients presenting CSF leaks and pneumocephalus.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Clinical and Radiological Characteristics of Traumatic Pneumocephalus after Traumatic Brain Injury

Objective

Traumatic pneumocephalus (TP) is a common complication of traumatic brain injury (TBI), which is characterized by the abnormal entrapment of air in the intracranial cavity after TBI to the meninges. The purpose of this study was to investigate the clinical and radiological characteristics related to TP associated with TBI.

Methods

From January 2013 to March 2018, the data from 71 patients with TP after TBI were collected. Demographic and clinical characteristics were investigated and the distribution of TP was investigated as radiological characteristics. The author compared the demographic characteristics of TP to the data from the Korean Neurotrauma Data Bank System (KNTDBS).

Results

There was a higher ratio of males in patients with TP compared with KNTDBS. The mean age was 48.4±20.5 years and the incidence was highest in those 41-60 years of age (42.3%). Surgical treatment was performed in 23.9% patients. The mortality associated with the TP was 4.2%. The most common cause of injury was a traffic accident (52.1%). TP was mainly located in the epidural space (53.5%) and showed a scatter pattern (60.6%). It was mostly located in the frontal and temporal area (81.7%). Skull fractures were observed in 40.8% in the temporal bone and 25.4% in the frontal bone.

Conclusion

The author identified epidemiology, clinical, and radiological characteristics of TP associated with TBI. Although this study has many limitations, the author believes it is worthwhile as it examines various characteristics of TP, which previously had relatively little clinical interest.

Rapidly fatal pneumococcal meningitis following non-penetrating traumatic brain injury

A previously healthy young man presented to hospital with severe traumatic brain injury following a motor vehicle collision. Within 24 hours of admission, and despite antibiotic coverage, he developed a fever. On the second day, the source of infection was discovered to be purulent pneumococcal meningitis. At 48 hours post-accident, he developed brain-stem death without evidence of raised intracranial pressure or trans-tentorial herniation. Initial CT scans of the head were essentially normal, but early repeat scans revealed evidence of pneumocephalus and possible frontal bone fracture. Current recommendations do not make room for targeted antibiotic prophylaxis in traumatic brain injury patients with traumatic skull fracture. We argue that our case demonstrates the need for aggressive targeted antibiotic prophylaxis in the presence of certain features such as frontal or sphenoid bone fracture and pneumocephalus.

Prevención y tratamiento de las infecciones del sitio operatorio en neurocirugía. Estado del arte

El manejo adecuado de las infecciones del sitio operatorio (ISO) en neurocirugía es fundamental para la disminución de la carga de morbilidad y mortalidad en estos pacientes. La sospecha y confirmación diagnóstica asociadas al aislamiento microbiológico son esenciales para asegurar el tratamiento oportuno y el adecuado gerenciamiento de antibióticos. En esta revisión se presenta de forma resumida los puntos fundamentales para la prevención y el tratamiento de infecciones del sitio operatorio en neurocirugía y se incluye un apartado sobre el uso de antibióticos intratecales/intraventriculares.

Infection Prevention in the Neurointensive Care Unit: A Systematic Review

Hospital-acquired infections are common in neurointensive care units. We sought to review interventions which may reduce infection rates in neurocritically ill populations. We conducted a systematic review of studies targeting adult patients in neuro-intensive care units (neuro-ICUs) with an intervention designed to prevent ICU-acquired infections. Our outcome of interest was change in the prevalence or rates of infection between active and control arms of these studies. We excluded studies based on the following criteria: no English full-text version available; pediatric population; non-neurosciences ICU population; pre- or intraoperative methods to prevent infection; lack of discrete data for infection rates/prevalence; studies that were purely observational in nature and did not test an intervention; and studies performed in resource limited settings. We initially retrieved 3716 results by searching the following databases: PubMed/MEDLINE, EMBASE via Ovid, and Cochrane CENTRAL via Ovid. No date or language limits were used in the search. Computerized deduplication was conducted using EndNote followed by a confirmatory manual review resulting in 3414 citations. An additional 19 manuscripts were identified through review of references. The screening process followed a standard protocol, using two screeners at the title/abstract level to determine relevance and at the full-text level to determine eligibility for inclusion. The 3427 titles/abstracts were independently screened by two board-certified neurointensivists to determine relevance for full-text review, and 3248 were rejected. The remaining 179 abstracts were reviewed in full text using predetermined inclusion/exclusion criteria. Ultimately, 75 articles met our inclusion criteria and were utilized in the final analysis. The reviewed literature highlights the need for collaborative, multi-disciplinary, and multi-pronged approaches to reduce infections. Rates of VRI, SSI, VAP, CAUTI, and CLABSI can approach zero with persistence and a team-based approach.

Acute Outcomes of Isolated Pneumocephali in Children After Minor Blunt Head Trauma

OBJECTIVES

We aimed to determine the prevalence of and adverse outcomes caused by pneumocephali in children with minor blunt head trauma who had no other intracranial injuries (ie, isolated pneumocephali).

METHODS

We conducted a secondary analysis of a public use dataset from a multicenter prospective study of pediatric minor head trauma. We included children younger than 18 years with Glasgow Coma Scale (GCS) scores of 14 or 15 and non-trivial mechanisms of injury who had cranial computed tomographies obtained. Patients with isolated pneumocephali were those without other traumatic brain injuries (TBIs) but could have non-depressed or basilar skull fractures (BSFs). We defined adverse outcomes as death, need for neurosurgery, or intubation more than 24 hours for TBI.

RESULTS

Pneumocephali occurred in 148 (1.0%; 95% confidence interval, 0.8%-1.2%) of 14,983 patients; 54 (36.5%) of 148 were isolated. Of these 54 patients, 42 (77.8%) had associated BSFs (7 of whom also had linear skull fractures) and 8 (14.8%) had associated linear skull fractures without BSFs; 4 patients (7.4%) had no fractures. Thirty-three patients (61.1%) had both GCS scores of 15 and no other signs of altered mental status. All patients with isolated pneumocephali and available descriptive data (n = 26) had small-sized pneumocephali. There were no deaths, neurosurgical interventions, or intubations for more than 24 hours for TBI (95% confidence interval for any of the outcomes, 0%-7.9%) in the 54 patients with isolated pneumocephali.

CONCLUSIONS

Children with isolated pneumocephali and GCS scores of 14 or 15 after minor blunt head trauma are unlikely to have adverse clinical outcomes.

Posttraumatic complications in pediatric skull fracture: dural sinus thrombosis, arterial dissection, and cerebrospinal fluid leakage

OBJECTIVE Skull fracture is associated with several intracranial injuries. The object of this study was to determine the rate of fracture associated with venous thrombosis, intracranial arterial dissection (ICAD), and cerebrospinal fluid (CSF) leakage in pediatric patients. Further, the authors aimed to highlight the features of pediatric skull fracture that predict poor neurological outcomes. METHOD In this retrospective study, the authors evaluated the records of 258 pediatric patients who had incurred a traumatic skull fracture in the period from 2009 to 2015. All the patients had undergone CT imaging, which was used to characterize the type of skull fracture and other important features, including intracranial hemorrhage. Patients with fracture extending to a dural sinus or proximal to major intracranial vessels had undergone vascular imaging to evaluate for venous thrombosis or arterial dissection. Clinical data were also reviewed for patients who had CSF leakage. RESULTS Two hundred fifty-eight patients had 302 skull fractures, with 11.6% having multiple fractures. Falling was the most common mechanism of injury (52.3%), and the parietal bone was most frequently involved in the fracture (43.4%). Diastatic fracture was associated with increased intracranial hemorrhage (p < 0.05). The rate of venous thrombosis was 0.4%, and the rate of ICAD was also 0.4%. The rate of CSF leakage was 2.3%. Skull base fracture was the only significant risk factor associated with an increased risk of CSF leakage (p < 0.05). There was a significant difference in fracture-related morbidity in patients younger than versus older than 2 years of age. Patients younger than 2 years had fewer intracranial hemorrhages (21.8% vs 38.8%) and fewer neurosurgical interventions (3.0% vs 12.7%) than the patients older than 2 years (p < 0.001). Moreover, skull fracture in the younger group was mostly caused by falling (81.2% vs 33.1%); in the older group, fracture was most often caused by vehicle-related accidents (35.7% vs 4.0%) and being struck by or against an object (19.1% vs 7.9%). Additionally, skull fracture location was analyzed based on the mechanism of injury. Parietal bone fracture was closely associated with falling, and temporal bone fracture was associated with being struck by or against an object (p < 0.05). Frontal bone fracture was more associated with being struck by or against an object and vehicle-related injury (p < 0.05) than with falling. Vehicle-related accidents and being struck by or against an object, as opposed to falling, were associated with increased surgical intervention (13.3% vs 16.2% vs 3.7%, respectively). CONCLUSIONS Pediatric skull fracture usually has a benign outcome in patients who fall and are younger than 2 years of age. Poor prognostic factors include diastasis, an age > 2 years, and fracture caused by vehicle-related accidents or being struck by or against an object. In this series, the rates of venous thrombosis and ICAD were low, and the authors do not advocate vascular imaging unless these disease entities are clinically suspected. Patients with skull base fracture should be closely monitored for CSF leakage.

Evidence-Based Medicine in Facial Trauma

This article provides the reader with a comprehensive review of high-level evidence-based medicine in facial trauma and highlights areas devoid of high-level evidence. The article is organized in the order one might approach a clinical problem: starting with the workup, followed by treatment considerations, operative decisions, and postoperative treatments. Individual injuries are discussed within each section, with an overview of the available high-level clinical evidence. This article not only provides a quick reference for the facial traumatologist, but also allows the reader to identify areas that lack high-level evidence, perhaps motivating future endeavors.

2017 Infectious Diseases Society of America's Clinical Practice Guidelines for Healthcare-Associated Ventriculitis and Meningitis

The Infectious Diseases Society of America (IDSA) Standards and Practice Guidelines Committee collaborated with partner organizations to convene a panel of 10 experts on healthcare-associated ventriculitis and meningitis. The panel represented pediatric and adult specialists in the field of infectious diseases and represented other organizations whose members care for patients with healthcare-associated ventriculitis and meningitis (American Academy of Neurology, American Association of Neurological Surgeons, and Neurocritical Care Society). The panel reviewed articles based on literature reviews, review articles and book chapters, evaluated the evidence and drafted recommendations. Questions were reviewed and approved by panel members. Subcategories were included for some questions based on specific populations of patients who may develop healthcare-associated ventriculitis and meningitis after the following procedures or situations: cerebrospinal fluid shunts, cerebrospinal fluid drains, implantation of intrathecal infusion pumps, implantation of deep brain stimulation hardware, and general neurosurgery and head trauma. Recommendations were followed by the strength of the recommendation and the quality of the evidence supporting the recommendation. Many recommendations, however, were based on expert opinion because rigorous clinical data are not available. These guidelines represent a practical and useful approach to assist practicing clinicians in the management of these challenging infections.

Pneumococcal polysaccharide vaccination administered early after neurotrauma or neurosurgery

OBJECTIVES

Pneumococcal vaccination is recommended to lower the risk of posttraumatic meningitis, and early vaccination may be of importance. After both trauma and central nervous system injury, immune-suppression may occur, which could affect T-cell function and the response to T-cell dependent vaccines. We therefore aimed to investigate the response to early vaccination with a T-cell independent pneumococcal polysaccharide vaccine (PPSV).

METHODS

Thirty-three patients with basilar skull fracture and 23 patients undergoing transsphenoidal pituitary gland surgery were vaccinated with PPSV within 10days after neurotrauma or neurosurgery. Twenty-nine neurosurgical patients vaccinated ⩾3weeks after neurotrauma or neurosurgery served as controls. Serotype-specific anti-polysaccharide binding IgG antibody levels to serotypes 4, 6B, 9V, 14, 18C, 19F and 23F were determined by enzyme immunoassay.

RESULTS

The vaccination was safe and a highly significant antibody response was found against all serotypes in all groups (p<0.001 for each of the serotypes). There were no differences between groups or in the group by time interaction in any of the serotypes. After early and late vaccination, protective levels were found in >80% for serotypes 9V, 14, 18C, 19F and 23F and in 70% and 50% for serotypes 6B and 4, respectively.

CONCLUSION

Patients vaccinated with PPSV within 10days after neurotrauma or neurosurgery respond similarly to those vaccinated after ⩾3weeks, indicating that PPSV can be administered early after neurotrauma or neurosurgery.

CLINICAL TRIALS REGISTRATION

NCT02806284.

The value of 3D-FIESTA MRI in detecting non-iatrogenic cerebrospinal fluid rhinorrhoea: correlations with endoscopic endonasal surgery

BACKGROUND

In this study, we investigated the value of three-dimensional (3D) fast-imaging employing steady-state acquisition (FIESTA) magnetic resonance imaging (MRI) in detecting non-iatrogenic cerebrospinal fluid (CSF) rhinorrhoea and compared it with regular MRI and 3D magnetisation prepared rapid acquisition gradient echo (MPRAGE) MRI sequences, as well as high-resolution computed tomography (HRCT) imaging. We also present the endoscopic experiences of such cases.

METHOD

From June 2011 to Feb 2016, 17 patients with non-iatrogenic cerebrospinal fluid rhinorrhoea were included. Seven patients had spontaneous rhinorrhoea, three patients had invasive tumours, and the remaining patients had traumatic aetiologies. All the patients underwent HRCT, regular MRI sequence imaging, 3D-MPRAGE MRI sequence imaging and 3D-FIESTA MRI sequence imaging for the preoperative evaluations of the leakages. For each patient, the CSF fistula site was confirmed by intraoperative neuronavigation and endoscopic findings. Statistical analyses were performed. All patients underwent endoscopic multilayer repair.

RESULTS

The sensitivities of the HRCT, regular MRI (T1 and T2), 3D-MPRAGE and 3D-FIESTA modalities for identifying CSF leakage were 58.8 %, (11.8 % and 29.4 %), 74.7 %, and 88.2 %, respectively. The origins of the leakages included the cribriform plate (18 %), ethmoidal fovea (23 %), lateral recess of the sphenoid (17 %), sellar floor (12 %), ethmoidal roof (12 %), junction of the fovea and cribriform plate (6 %) and the junction of sellar and sphenoidal planum (6 %). Two patients required repair. The first was under local anaesthesia when the nasal packing was removed, and the second underwent repair at the same site a half-year later due to hydrocephalus. Lumbar drainage was performed in all cases. No major complications were encountered.

CONCLUSIONS

The endoscopic endonasal approach is safe and effective for the treatment of CSF rhinorrhoea. The 3D-FIESTA MR modality is superior to 3D-MPRAGE MR and HRCT in the depiction of the CSF fistula site. Due to its non-invasive and reliable properties, 3D-FIESTA MR should be the preferred preoperative examination for the patients with non-iatrogenic CSF rhinorrhoea.

Treatment of Temporal Bone Fractures

Traumatic injury to the temporal bone can lead to significant morbidity or mortality and knowledge of the pertinent anatomy, pathophysiology of injury, and appropriate management strategies is critical for successful recovery and rehabilitation of such injured patients. Most temporal bone fractures are caused by motor vehicle accidents. Temporal bone fractures are best classified as either otic capsule sparing or otic capsule disrupting-type fractures, as such classification correlates well with risk of concomitant functional complications. The most common complications of temporal bone fractures are facial nerve injury, cerebrospinal fluid (CSF) leak, and hearing loss. Assessment of facial nerve function as soon as possible following injury greatly facilitates clinical decision making. Use of prophylactic antibiotics in the setting of CSF leak is controversial; however, following critical analysis and interpretation of the existing classic and contemporary literature, we believe its use is absolutely warranted.

Posttraumatic Intracranial Tuberculous Subdural Empyema in a Patient with Skull Fracture

Intracranial tuberculous subdural empyema (ITSE) is extremely rare. To our knowledge, only four cases of microbiologically confirmed ITSE have been reported in the English literature to date. Most cases have arisen in patients with pulmonary tuberculosis regardless of trauma. A 46-year-old man presented to the emergency department after a fall. On arrival, he complained of pain in his head, face, chest and left arm. He was alert and oriented. An initial neurological examination was normal. Radiologic evaluation revealed multiple fractures of his skull, ribs, left scapula and radius. Though he had suffered extensive skull fractures of his cranium, maxilla, zygoma and orbital wall, the sustained cerebral contusion and hemorrhage were mild. Eighteen days later, he suddenly experienced a general tonic-clonic seizure. Radiologic evaluation revealed a subdural empyema in the left occipital area that was not present on admission. We performed a craniotomy, and the empyema was completely removed. Microbiological examination identified Mycobacterium tuberculosis (M. tuberculosis). After eighteen months of anti-tuberculous treatment, the empyema disappeared completely. This case demonstrates that tuberculosis can induce empyema in patients with skull fractures. Thus, we recommend that M. tuberculosis should be considered as the probable pathogen in cases with posttraumatic empyema.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

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

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.

CONCLUSIONS

Extensive anterior skull base fractures often require aggressive treatment to provide the greatest long-term 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.

Management of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations

BACKGROUND

Management strategies employed for cases of cerebrospinal fluid (CSF) rhinorrhea vary widely because of limited evidence-based guidance.

METHODS

A systematic review of the literature was performed using PubMed, EMBASE, and Cochrane databases from January 1990 through September 2014 to examine 5 endoscopic repair techniques and 8 perioperative management strategies for CSF rhinorrhea. Benefit-harm assessments, value judgments, and recommendations were made based on the available evidence. Study exclusion criteria were language other than English, pre-1990 studies, case reports, and nonrhinologic leak. All authors agreed on recommendations through an iterative process.

RESULTS

We reviewed 67 studies examining 13 practices pertinent to the management of CSF rhinorrhea, reaching a highest aggregate grade of evidence of B. The literature does not support the routine use of prophylactic antibiotics or lumbar drainage. Various endoscopic repair materials show similar success rates; however, larger defects may benefit from vascularized grafts. There were no relevant studies to address postoperative activity restrictions.

CONCLUSION

Despite relatively low levels of evidence, recommendations for the management of CSF rhinorrhea can be made based on the current literature. Higher-level studies are needed to better determine optimal clinical management approaches.

Diagnosis of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations

BACKGROUND

Diagnostic strategies employed for cases of cerebrospinal fluid (CSF) rhinorrhea vary widely due to limited evidence-based guidance.

METHODS

A systematic review of the literature was performed using PubMed, EMBASE, and Cochrane databases from January 1990 through September 2014, to examine 9 diagnostic and localization modalities for CSF rhinorrhea. Benefit-harm assessments, value judgments and recommendations were made based on the available evidence. Study exclusion criteria were language other than English, pre-1990 studies, case reports, and nonrhinologic leak. All authors agreed on recommendations through an iterative process.

RESULTS

We reviewed 68 studies examining 9 practices pertinent to the diagnosis of CSF rhinorrhea, with a highest aggregate grade of evidence of C. The literature does not support the use of the ring sign, glucose testing, radionuclide cisternography (RNC), or computed tomography cisternography (CTC) for identification of CSF leak. Beta-2 transferrin is the most reliable confirmatory test for CSF leak. High-resolution CT (HRCT) is then recommended as the first-line study for localization. Magnetic resonance cisternography (MRC) should be used for CSF leak identification as a second line for each of these if beta-2 transferrin is not available or if HRCT is ambiguous. Intrathecal fluorescein (IF) may also be of benefit in certain clinical scenarios.

CONCLUSION

Despite relatively low levels of evidence, recommendations for the diagnosis and management of CSF rhinorrhea can be made based on the current literature. Higher-level studies are needed to better determine optimal diagnostic and clinical management approaches.

Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures

BACKGROUND

Basilar skull fractures predispose patients to meningitis because of the possible direct contact of bacteria in the paranasal sinuses, nasopharynx or middle ear with the central nervous system (CNS). Cerebrospinal fluid (CSF) leakage has been associated with a greater risk of contracting meningitis. Antibiotics are often given prophylactically, although their role in preventing bacterial meningitis has not been established.

OBJECTIVES

To evaluate the effectiveness of prophylactic antibiotics for preventing meningitis in patients with basilar skull fractures.

SEARCH METHODS

We searched CENTRAL (2014, Issue 5), MEDLINE (1966 to June week 1, 2014), EMBASE (1974 to June 2014) and LILACS (1982 to June 2014). We also performed an electronic search of meeting proceedings from the American Association of Neurological Surgeons (1997 to September 2005) and handsearched the abstracts of meeting proceedings of the European Association of Neurosurgical Societies (1995, 1999 and 2003).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any antibiotic versus placebo or no intervention. We also identified non-RCTs to perform a separate meta-analysis in order to compare results.

DATA COLLECTION AND ANALYSIS

Three review authors independently screened and selected trials, assessed risk of bias and extracted data. We sought clarification with trial authors when needed. We pooled risk ratios (RRs) for dichotomous data with their 95% confidence intervals (CIs) using a random-effects model. We assessed the overall quality of evidence using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach.

MAIN RESULTS

In this update we did not identify any new trials for inclusion. We included five RCTs with 208 participants in the review and meta-analysis. We also identified 17 non-RCTs comparing different types of antibiotic prophylaxis with placebo or no intervention in patients with basilar skull fractures. Most trials presented insufficient methodological detail. All studies included meningitis in their primary outcome. When we evaluated the five included RCTs, there were no significant differences between antibiotic prophylaxis groups and control groups in terms of reduction of the frequency of meningitis, all-cause mortality, meningitis-related mortality and need for surgical correction in patients with CSF leakage. There were no reported adverse effects of antibiotic administration, although one of the five RCTs reported an induced change in the posterior nasopharyngeal flora towards potentially more pathogenic organisms resistant to the antibiotic regimen used in prophylaxis. We performed a subgroup analysis to evaluate the primary outcome in patients with and without CSF leakage. We also completed a meta-analysis of all the identified controlled non-RCTs (enrolling a total of 2168 patients), which produced results consistent with the randomised data from the included studies.Using the GRADE approach, we assessed the quality of trials as moderate.

AUTHORS' CONCLUSIONS

Currently available evidence from RCTs does not support prophylactic antibiotic use in patients with basilar skull fractures, whether there is evidence of CSF leakage or not. Until more research is available, the effectiveness of antibiotics in patients with basilar skull fractures cannot be determined because studies published to date are flawed by biases. Large, appropriately designed RCTs are needed.

Lower response to early T-cell-dependent vaccination after neurotrauma or neurosurgery in adults

BACKGROUND

Recent international guidelines recommend vaccination with a 13-valent pneumococcal conjugate vaccine to reduce the risk of meningitis after neurotrauma with cerebrospinal fluid leak. The antibody response and optimal time point for vaccination have not been established and because the risk of meningitis is at the highest shortly after trauma, early vaccination is preferable. This study aimed to investigate the antibody response and to ensure that central nervous system injury-induced immunodepression did not affect the response to a T-cell-dependent conjugate vaccine when administered shortly after the injury.

METHODS

So as not to interfere with routine pneumococcal vaccination, a conjugate vaccine against Haemophilus influenza type b (Hib) was chosen for the study. Thirty-three patients with basilar skull fracture and 23 patients undergoing transsphenoidal pituitary gland surgery were vaccinated within 10 days after trauma/surgery and 29 control patients at least three weeks after trauma/surgery. Sera were collected pre- and post-vaccination for analysis of anti-Hib concentration.

RESULTS

Four patients with post-vaccination target antibody concentration before vaccination were excluded from analysis. In the neurotrauma and neurosurgery groups 10/32 (31%) and 5/20 (25%) patients, respectively, were non-responders compared with 3/29 (10%) in the control group. Log10 anti-Hib concentrations in the neurotrauma, neurosurgery and control groups were 1.52 ± 0.15, 1.38 ± 0.15 and 1.81 ± 0.12 μg/ml, respectively.

CONCLUSIONS

The majority of the patients responded to vaccination. However, the number of responders was significantly decreased and antibody concentration significantly lower in patients vaccinated early after the trauma/surgery. Investigation of the pneumococcal conjugate vaccine response in neurotrauma patients is therefore urgent.

Systematic review of the literature and evidence-based recommendations for antibiotic prophylaxis in trauma: results from an Italian consensus of experts

BACKGROUND

Antibiotic prophylaxis is frequently administered in severe trauma. However, the risk of selecting resistant bacteria, a major issue especially in critical care environments, has not been sufficiently investigated. The aim of the present study was to provide guidelines for antibiotic prophylaxis for four different trauma-related clinical conditions, taking into account the risks of antibiotic-resistant bacteria selection, thus innovating previous guidelines in the field.

METHODS

The MEDLINE database was searched for studies comparing antibiotic prophylaxis to controls (placebo or no antibiotic administration) in four clinical traumatic conditions that were selected on the basis of the traumatic event frequency and/or infection severity. The selected studies focused on the prevention of early ventilator associated pneumonia (VAP) in comatose patients with traumatic brain injury, of meningitis in severe basilar skull fractures, of wound infections in long-bone open fractures. Since no placebo-controlled study was available for deep surgical site-infections prevention in abdominal trauma with enteric contamination, we compared 24-hour and 5-day antibiotic prophylaxis policies. A separate specific research focused on the question of antibiotic-resistant bacteria selection caused by antibiotic prophylaxis, an issue not adequately investigated by the selected studies. Randomised trials, reviews, meta-analyses, observational studies were included. Data extraction was carried out by one author according to a predefined protocol, using an electronic form. The strength of evidence was stratified and recommendations were given according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria.

RESULTS

Uncertain evidence deserving further studies was found for two-dose antibiotic prophylaxis for early VAP prevention in comatose patients. In the other cases the risk of resistant-bacteria selection caused by antibiotic administration for 48 hours or more, outweighed potential benefits.

CONCLUSIONS

When accounting for antibiotic-resistant bacteria selection we found no evidence in favour of antibiotic prophylaxis lasting two or more days in the studied clinical conditions.

Immediate single-stage reconstruction of complex frontofaciobasal injuries: part I

Objective To determine if immediate (within 6 hours of adequate resuscitation) single-stage repair of complex craniofacial injuries could be accomplished with acceptable morbidity and mortality taking into consideration the cosmetic appearance of the patient. Patients and Methods A total of 26 patients (19 men, 7 women) ranging in age from 8 to 58 years with Glasgow Coma Scale scores of 5 to 15 all had a combined single-stage repair of their complex craniofacial injuries within 6 hours of their admission. After initial assessment and adequate resuscitation, they were evaluated with three-dimensional computed tomography of the face and head. Coronal skin flap was used for maximum exposure for frontal sinus exenteration as well as dural repair, cortical debridement, calvarial reconstruction, and titanium mesh placement. Results Neurosurgical outcome at both the early and late evaluations was judged as good in 22 of 26 patients (85%), moderate in 3 of 26 (11%), and poor in 1 of the 26 (3.8%). Cosmetic surgical outcome at the early evaluation showed 17 of 26 (65%) to be excellent, 4 of 26 (15.5%) to be good, 4 patients (15.5%) to be fair, and 1 patient (3.8%) to be poor. At the late reevaluation, the fair had improved to good with an additional reconstructive procedure, and the poor had improved to fair with another surgery. There was no calvarial osteomyelitis, graft resorption, or intracranial abscess. Complications included three patients (11%): one (3.8%) had tension pneumocephaly and meningitis, one (3.8%) had delayed cerebrospinal fluid leak with recurrent attacks of meningitis, and one had a maxillary sinus infection (3.8%) secondary to front maxillary fistula. Conclusion The immediate single-stage repair of complex craniofacial injuries can be performed with acceptable results, a decreased need for reoperation, and improved cosmetic and functional outcomes.

Evidence-based clinical management and utilization of new technology in European neurosurgery

BACKGROUND

Evidence-based medicine (EBM) has become one of the pillars of modern patient care. However, neurosurgery has always been an experience-based and technology-driven discipline, and it remains unknown to which extent European neurosurgeons follow high-level evidence-based recommendations.

METHODS

We conducted a Web-based survey with a 15-item questionnaire about evidence-based clinical management and utilization of new technology among European neurosurgeons. Two different sum scores were calculated from the questions concerning clinical practice; evidence-based treatment score and new technology score. A high evidence-based treatment score means that more clinical conditions (i.e., study questions) were managed in compliance with the available highest levels of evidence from published clinical trials. A high new technology score reflects the use of a high number of modern tools in neurosurgical practice.

RESULTS

A total of 239 neurosurgeons from 30 different European countries answered the questionnaire. There were large variations among European neurosurgeons in providing evidence-based care and in utilization of various modern tools. There were significant regional differences in evidence-based treatment scores and modern technology scores with higher scores in northern and western Europe. High-volume institutions were not associated with better evidence-based treatment scores, but had significantly higher new technology scores. There were significantly higher new technology scores at university hospitals and a trend towards higher evidence-based treatment scores compared to other hospitals.

CONCLUSIONS

Clinical management in neurosurgery does not always comply with the best available evidence and there are large regional differences in clinical management and in utilization of various modern tools. The position of evidence-based medicine in European neurosurgery seems weak and this may be a threat to the quality of care.

[Case of primary central nervous system lymphoma after open head injury]

A 65-year-old man had suffered contusion of the left frontal lobe of the brain with a skull base fracture, pneumocephalus, and cerebrospinal fluid (CSF) leakage. He was treated with ceftriaxone 4 g/day for 14 days, but after 1 month he developed multiple cranial nerve palsies (bilateral III-X). CSF contained increased levels of protein (96 mg/dl) and mononuclear cells (72 cells/mm³), and low glucose levels (40 mg/dl, blood sugar 120 mg/dl), but no malignant cells were detected. Magnetic resonance imaging (MRI) disclosed swelling in multiple cranial nerves with Gd enhancement. Anti-biotic and antifungal therapy remitted the facial, glossopharyngeal, and vagus nerve palsies and reduced the Gd-enhancement lesion, as detected by MRI. However, the eyes were bilaterally dilated and medially fixed, and hearing impairments persisted. After 3 months, follow-up MRIs revealed the presence of Gd-enhanced small masses at the ventral pontine base, medulla, and cervicomedullary junctions despite a lack of change in neurological symptoms. Those lesions subsided favorably upon treatment with intravenous and oral corticosteroids. After 1 year and 9 months, Gd-enhanced small cystic masses appeared on the medulla and cerebellum. An open biopsy of the cerebellar tonsillar lesions revealed diffuse large B cell lymphoma. Although the development of primary central nervous system lymphoma after open head injury and infection has not been reported to date, central nervous system lymphomas may mimic diverse neurological diseases. Brain biopsy remains the only definitive diagnosis, and thus should be pursued if blood and CSF markers appear normal.

Is posttraumatic cerebrospinal fluid fistula a predictor of posttraumatic meningitis? A US Nationwide Inpatient Sample database study

Object

Various factors have been reported in literature to be associated with the development of posttraumatic meningitis. There is a paucity of data regarding skull fractures and facial fractures leading to CSF leaks and their association with the development of meningitis. The primary objective of this study was to analyze the US Nationwide Inpatient Sample (NIS) database to elucidate the factors associated with the development of posttraumatic meningitis. A secondary goal was to analyze the overall hospitalization cost related to posttraumatic meningitis and factors associated with that cost.

Methods

The NIS database was analyzed to identify patients admitted to hospitals with a diagnosis of head injury from 2005 through 2009. This data set was analyzed to assess the relationship of various clinical parameters that may affect the development of posttraumatic meningitis using binary logistic regression models. Additionally, the overall hospitalization cost for the head injury patients who did not undergo any neurosurgical intervention was further categorized into quartile groups, and a regression model was created to analyze various factors responsible for escalating the overall cost of the hospital stay.

Results

A total of 382,267 inpatient admissions for head injury were analyzed for the 2005–2009 period. Meningitis was reported in 0.2% of these cases (708 cases). Closed skull base fractures, open skull base fractures, cranial vault fractures, and maxillofacial fractures were reported in 20,524 (5.4%), 1089 (0.3%), 5064 (1.3%), and 88,649 (23.2%) patients, respectively. Among these patients with fractures, meningitis was noted in 0.17%, 0.18%, 0.05%, and 0.10% admissions, respectively. Cerebrospinal fluid rhinorrhea was reported in 453 head injury patients (0.1%) and CSF otorrhea in 582 (0.2%). Of the patients reported to have CSF rhinorrhea, 35 (7.7%) developed meningitis, whereas in the cohort with CSF otorrhea, 15 patients (2.6%) developed meningitis. Cerebrospinal fluid rhinorrhea (p < 0.001, OR 22.8, 95% CI 15.6–33.3), CSF otorrhea (p < 0.001, OR 9.2, 95% CI 5.2–16.09), and major neurosurgical procedures (p < 0.001, OR 5.6, 95% CI 4.8–6.5) were independent predictors of meningitis. Further, CSF rhinorrhea (p < 0.001, OR 2.0, 95% CI 1.6–2.7), CSF otorrhea (p < 0.001, OR 2.3, 95% CI 1.9–2.7), and posttraumatic meningitis (p < 0.001, OR 3.1, 95% CI 2.5–3.8) were independent factors responsible for escalating the cost of head injury in cases not requiring any major neurosurgical intervention.

Conclusions

Cerebrospinal fluid rhinorrhea and CSF otorrhea are independent predictors of posttraumatic meningitis. Furthermore, meningitis and CSF fistulas may independently lead to significantly increased cost of hospitalization in head injury patients not undergoing any major neurosurgical intervention.

[Diagnosis and treatment of injuries to the frontal skull base]

The role of ENT surgery in the management of anterior skull base defects has become increasingly important in recent years. Transnasal endoscopic surgical techniques and intraoperative navigation enable a minimally invasive approach in a large proportion of patients, thus helping to avoid morbidity typically associated with neurosurgical subfrontal approaches. Whereas traffic accidents and sport injuries are the main causes of anterior skull base trauma in the civilian setting, penetrating injuries caused by gunshots and improvised explosive devices (IEDs) play an increasing role in the military arena and terroristic attacks. Minor injuries to the anterior skull base are usually managed by ENT surgeons. Major injuries, involving the midface or neurocranium, require an interdisciplinary approach including maxillofacial surgeons and neurosurgeons. A centre for head and neck medicine and surgery is an ideal setting for such interdisciplinary teams to provide appropriate care for patients with complex skull base trauma in cooperation with ophthalmologists and interventional neuoradiologists. The present article describes concepts for the treatment of anterior skull base trauma established at the head, neck and skull base center at the Ulm military hospital in Germany.

Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures

BACKGROUND

Basilar skull fractures (BSF) predispose patients to meningitis because of the possible direct contact of bacteria in the paranasal sinuses, nasopharynx or middle ear with the central nervous system (CNS). Cerebrospinal fluid (CSF) leakage has been associated with a greater risk of contracting meningitis. Antibiotics are often given prophylactically, although their role in preventing bacterial meningitis is not established.

OBJECTIVES

To evaluate the effectiveness of prophylactic antibiotics for preventing meningitis in patients with BSF.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 1), which contains the Cochrane Acute Respiratory Infections (ARI) Group's Specialised Register, MEDLINE (1966 to February 2011), EMBASE (1974 to February 2011) and LILACS (1982 to February 2011). We also performed an electronic search of meeting proceedings from the American Association of Neurological Surgeons (1997 to September 2005) and handsearched the abstracts of meeting proceedings of the European Association of Neurosurgical Societies (1995, 1999 and 2003).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any antibiotic versus placebo or no intervention. We also identified non-RCTs to perform a separate meta-analysis to compare results.

DATA COLLECTION AND ANALYSIS

At least two authors independently appraised trial quality and extracted data for each trial.

MAIN RESULTS

We identified five RCTs and 17 non-RCTs comparing different types of antibiotic prophylaxis with placebo or no intervention in patients with BSF. Most trials presented insufficient methodological detail. All studies included meningitis in their primary outcome. Overall, we evaluated 208 participants from the five RCTs that were considered suitable for inclusion in the meta-analysis. There were no significant differences between antibiotic prophylaxis groups and control groups in terms of reduction of the frequency of meningitis, all-cause mortality, meningitis-related mortality, and need for surgical correction in patients with CSF leakage. There were no reported adverse effects of antibiotic administration, although one of the five RCTs reported an induced change in the posterior nasopharyngeal flora towards potentially more pathogenic organisms resistant to the antibiotic regimen used in prophylaxis. We performed a subgroup analysis to evaluate the primary outcome in patients with and without CSF leakage. We also completed a meta-analysis of all the identified controlled non-RCTs (enrolling a total of 2168 patients), producing results consistent with the randomised data.

AUTHORS' CONCLUSIONS

Currently available evidence from RCTs does not support prophylactic antibiotic use in patients with BSF, whether there is evidence of CSF leakage or not. Until more research is completed, the effectiveness of antibiotics in patients with BSF cannot be determined because studies published to date are flawed by biases. Large, appropriately designed RCTs are needed.

Traumatic brain injury: review of current management strategies

Head injury is a common condition with a high morbidity and mortality. Serious intracranial haematomas require early recognition and evacuation to maximise chances of independent outcomes. Recent organisational changes have promoted the development of trauma units and major trauma centres where patients can go through triage and be managed in an appropriate environment, and the development of management pathways in intensive treatment units has resulted in improvements in the outcome of traumatic brain injuries. Evidence for the treatment of cerebral perfusion pressure, and management of hyperventilation, osmotherapy, tracheostomy, and leakage of cerebrospinal fluid (CSF) has accumulated during the last decade and is important in the management of patients in all clinical settings. Since head injury is commonly associated with maxillofacial injuries, this review will be relevant to all who deal with this aspect of trauma.

Prophylactic antibiotics and anticonvulsants in neurosurgery

The prophylactic administration of antibiotics to prevent infection and the prophylactic administration of anticonvulsants to prevent first seizure episodes are common practice in neurosurgery. If prophylactic medication therapy is not indicated, the patient not only incurs the discomfort and the inconvenience resulting from drug treatment but is also unnecessarily exposed to adverse drug reactions, and incurs extra costs. The main situations in which prophylactic anticonvulsants and antibiotics are used are described and those situations we found controversial in the literature and lack further investigation are identified: anticonvulsants for preventing seizures in patients with chronic subdural hematomas, antiepileptic drugs for preventing seizures in those suffering from brain tumors, antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures, and antibiotic prophylaxis for the surgical introduction of intracranial ventricular shunts.In the following we present systematic reviews of the literature in accordance with the standard protocol of The Cochrane Collaboration to evaluate the effectiveness of the use of these prophylactic medications in the situations mentioned. Our goal was to efficiently integrate valid information and provide a basis for rational decision-making.

Pneumocephalus: case illustrations and review

BACKGROUND

Pneumocephalus is commonly encountered after neurosurgical procedures but can also be caused by craniofacial trauma and tumors of the skull base and rarely, can occur spontaneously. Contributing factors for the development of pneumocephalus include head position, duration of surgery, nitrous oxide (N(2)O) anesthesia, hydrocephalus, intraoperative osmotherapy, hyperventilation, spinal anesthesia, barotauma, continuous CSF drainage via lumbar drain, epidural anesthesia, infections, and neoplasms. Clinical presentation includes headaches, nausea and vomiting, seizures, dizziness, and depressed neurological status. In this article, we review the incidence, mechanisms, precipitating factors, diagnosis, and management of pneumocephalus. Search of Medline, databases, and manual review of article bibliographies. Considering four case illustrations that typify pneumocephalus in clinical practice, we discuss the common etiologies, and confirm the diagnosis with neuroimaging and management strategies. Avoidance of contributing factors, high index of suspicion, and confirmation with neuroimaging are important in attenuating mortality and morbidity. A significant amount of pneumocephalus can simulate a space-occupying lesion. Supplemental oxygen increases the rate of absorption of pneumocephalus.

Treatment of pneumocephalus after endoscopic sinus and microscopic skull base surgery

BACKGROUND

Pneumocephalus is a rare complication of endoscopic sinus surgery (ESS) and microscopic skull base surgery (MSBS). Postoperatively, patients often present with headache and altered mental status. Unrepaired leaks are associated with an increased risk of ascending meningitis. Standard treatment of pneumocephalus after ESS or MSBS has not been addressed in the literature.

METHODS

The study involved a retrospective review of patients at an academic tertiary care center with pneumocephalus after ESS or MSBS.

RESULTS

Ten cases of pneumocephalus were identified, 8 after ESS and 2 after MSBS. Seven ESS defects were very small (<3 mm). The remaining three had defects more than 1 cm. Six of the 8 ESS patients had spontaneous resolution of their cerebrospinal fluid (CSF) leak and pneumocephalus, whereas all patients with larger defects failed conservative therapy with lumbar drainage. Lumbar drainage worsened the pneumocephalus in the MSBS patients. Despite resolution of pneumocephalus in many patients, all were recommended to undergo endoscopic exploration due to concern for increased risk of meningitis in unrepaired defects. Endoscopic repair was necessary in 8 cases. Repairs required a mucosal graft with or without a bone graft. Many spontaneously healed defects were found to be very tenuous. In 2 cases, patients were found to have dense scar over the defect not requiring repair.

CONCLUSIONS

In patients with pneumocephalus after ESS or MSBS, consideration should be given to endoscopic exploration and repair of the defect with mucosal grafting. Even if spontaneous resolution has occurred, there may be increased risk of ascending meningitis through the thin or incompletely regenerated mucosa.

Epistaxis as the only initial symptom in pediatric naso-orbital-ethmoid fracture complicated with meningitis

Epistaxis is a frequent finding in patients with facial trauma. Herein, we report an unusual presentation of pediatric naso-orbital-ethmoid (NOE) fracture with epistaxis as the only initial symptom. The course of the patient's condition was later complicated by meningitis, related in part to the delay in diagnosis. A 3-year-old girl with preexisting upper respiratory symptoms was involved in a traffic accident, sustaining blunt trauma to the right side of her face. During the initial examination, only right-sided epistaxis was noted. Five days later, she developed febrile convulsion and was admitted to the intensive care unit with other signs of meningitis such as mental status change and neck stiffness. Her craniofacial computed tomographic scan showed a right-sided NOE fracture with minimal displacement and without dura tear. The cerebrospinal fluid culture grew Streptococcus pneumoniae, which may be due to ascending infection as a result of cribriform plate fracture. Intravenous antibiotic therapy was initiated with good response, and she was discharged from the hospital after 2 weeks. The presence of epistaxis and periorbital bruise, together with other symptoms and signs, helps in the identification of NOE and cribriform plate fracture. A high index of suspicion with repetitive computed tomographic scans is necessary to achieve correct early diagnosis. Parental antibiotic therapy is indicated if ascending cerebrospinal fluid infection develops.

Multidisciplinary surgical approach for cerebrospinal fluid leak in children with complex head trauma

INTRODUCTION

Post-traumatic cerebrospinal fluid leak from the anterior cranial fossa in children may be isolated or combined with severe facial and calvarial injury. Untreated leak may result with meningitis, hydrocephalus, and abnormal neurocognitive development.

PATIENTS AND METHODS

We present nine children, ages 4-16 years, with complicated craniofacial injury treated by a combined subcranial and intracranial approach. A continuous lumbar drainage was kept for several days, and prophylactic antibiotics and anti-convulsive medications were routinely given. A multidisciplinary approach including discussion before surgery about other surgical options (endoscopic extracranial and intracranial alone) were performed.

RESULTS

None of the operated children had episodes of meningitis/leak after the combined approach, suggesting that appropriate sealing of the base of the skull has been achieved. There was no mortality, and the long-term follow-up showed good developmental and cosmetic results. Most of the children had significant brain contusions prior to surgery; however, these did not progress as minimal retraction was enabled by the extensive subcranial and intracranial approach.

CONCLUSIONS

Child's age, anatomy of the bone, extent of cranial injury, and clinical parameters should be seriously considered when choosing the technical methods as for sealing base of skull and reconstruction of facial/cranial bones. Young age does not seem to be a contraindication to the combined approach, thus, we recommend considering it in extensive base of skull fractures when concomitant cranial, maxillofacial, and orbital fractures coexist, as alternative options may not suffice in these cases.

Pneumocephalus Following Severe Head Trauma

It is important to be alert to the possibility of pneumocephalus in patients with head injury. Pneumocephalus is a potentially lethal complication in patients with craniofacial fractures following severe head trauma. A patient presented with intracranial air after he fell down from a height of 4 m. The patient recovered without any neurological deficits after conservative treatment. A time sequence of cerebral CT scans shows how the pneumocephalus developed and finally resolved without surgical intervention. The etiology, diagnosis, treatment and possible complications of this injury are discussed briefly.

Trauma

In terms of cost and years of potential lives lost, injury arguably remains the most important public health problem facing the United States. Care of traumatically injured patients depends on early surgical intervention and avoiding delays in the diagnosis of injuries that threaten life and limb. In the critical care phase, successful outcomes after injury depend almost solely on diligence, attention to detail, and surveillance for iatrogenic infections and complications.

Intraventricular tension pneumocephalus and cervical subarachnoid pneumorrhachis in a bull mastiff dog after craniotomy

An eight-year-old bull mastiff dog underwent a craniotomy for surgical excision of an olfactory lobe meningioma. Rapidly progressive neurological deficits with cervical pain developed within the early postoperative period. Intraventricular and cervical subarachnoid space air accumulation (pneumorrhachis) was identified through magnetic resonance imaging and computed tomography. Repair of a dural defect using synthetic dura substitute resulted in gradual resolution of neurological signs attributable to the tension pneumocephalus and subarachnoid space pneumorrhachis. Regrowth of the meningioma was not observed. Postoperative intraventricular tension pneumocephalus and air accumulation within subarachnoid space are uncommon but life-threatening complications of intracranial surgery. Early diagnosis and treatment can result in a satisfactory outcome.

SURGICAL MANAGEMENT OF ANTERIOR CRANIAL BASE FRACTURES WITH CEREBROSPINAL FLUID FISTULAE

OBJECTIVE

The management of cerebrospinal fluid (CSF) fistulae after anterior cranial base fracture remains a surgical challenge. We reviewed our results in the repair of CSF fistulae complicating multiple anterior cranial base fractures via a combined intracranial extradural and intradural approach and describe a treatment algorithm derived from this experience.

METHODS

We retrospectively reviewed the files of 209 patients with an anterior cranial base fracture complicated by a CSF fistula who were admitted between 1980 and 2003 to Liège State University Hospital. Among those patients, 109 had a persistent CSF leak or radiological signs of an unhealed dural tear. All underwent the same surgical procedure, with combined extradural and intradural closure of the dural tear.

RESULTS

Of the 109 patients, 98 patients (90%) were cured after the first operation. Persistent postoperative CSF rhinorrhea occurred in 11 patients (10%), necessitating an early complementary surgery via a transsphenoidal approach (7 patients) or a second-look intracranial approach (4 patients). No postoperative neurological deterioration attributable to increasing frontocerebral edema occurred. During the mean follow-up period of 36 months, recurrence of CSF fistula was observed in five patients and required an additional surgical repair procedure.

CONCLUSION

The closure of CSF fistulae after an anterior cranial base fracture via a combined intracranial extradural and intradural approach, which allows the visualization and repair of the entire anterior base, is safe and effective. It is essentially indicated for patients with extensive bone defects in the cranial base, multiple fractures of the ethmoid bone and the posterior wall of the frontal sinus, cranial nerve involvement, associated lesions necessitating surgery such as intracranial hematomas, and post-traumatic intracranial infection. Rhinorrhea caused by a precisely located small tear may be treated with endoscopy.