Development of Anterior Cranial Fossa Dural Arteriovenous Fistula and Supraclinoid Internal Carotid Artery Pseudoaneurysm Following Frontobasal Trauma: A Case Report and Literature Review

Cerebrovascular injuries resulting from frontobasal head trauma represent a range of imaging and clinical presentations. Severe cerebrovascular injuries such as vessel transection commonly present with profound neurological deficits and are often easily identified with routine imaging. However, small intimal injuries and dissections may be challenging to detect and may be clinically silent or masked by additional injuries in the setting of polytrauma. The onset of symptoms and complications from cerebrovascular injuries may be delayed from the time of initial presentation, and failure to recognize and diagnose these injuries may result in devastating outcomes if management is delayed. In this case report, we present a case of frontobasal craniofacial trauma that resulted in an anterior cranial fossa dural arteriovenous fistula (ACF-dAVF) and supraclinioid segment internal carotid artery (ICA) pseudoaneurysm.

CSF Leaks due to Electric Scooter Injury

BACKGROUND

There has been a rapid increase in electric motorized scooter (e-scooter) usage after the introduction of dockless, shareable devices.

METHODS

Case series from three tertiary hospitals in Los Angeles between May-September 2019.

RESULTS

Five patients had skull base fractures and CSF leaks or pneumocephalus after e-scooter accident, none wore helmets. Two patients were treated with observation alone, two patients were treated with lumbar drain or external ventriculostomy placement, and one patient died of their injuries prior to definitive management.

CONCLUSION

Without appropriate safety policies in place, the number of such injuries may increase as the use of e-scooters increase. Laryngoscope, 131:E1035-E1037, 2021.

Skull Base Trauma: Clinical Considerations in Evaluation and Diagnosis and Review of Management Techniques and Surgical Approaches

Traumatic injuries to the skull base can involve critical neurovascular structures and present with symptoms and signs that must be recognized by physicians tasked with management of trauma patients. This article provides a review of skull base anatomy and outlines demographic features in skull base trauma. The manifestations of various skull base injuries, including CSF leaks, facial paralysis, anosmia, and cranial nerve injury, are discussed, as are appropriate diagnostic and radiographic testing in patients with such injuries. While conservative management is sometimes appropriate in skull base trauma, surgical access to the skull base for reconstruction of traumatic injuries may be required. A variety of specific surgical approaches to the anterior cranial fossa are discussed, including the classic anterior craniofacial approach as well as less invasive and newer endoscope-assisted approaches to the traumatized skull base.

Management of Battlefield Injuries to the Skull Base

High velocity skull base injuries on the battlefield are unique in comparison to most civilian sector trauma. With more than 43,000 United States military personnel injuries during Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF), the most recent conflicts in Iraq and Afghanistan have significantly expanded the understanding of the physiology of modern battlefield trauma and how to appropriately address these injuries. The acute care principles of effective triage, airway management, and hemorrhage control in these injuries can be life saving and are reviewed here. Specific injury patterns and battlefield examples are reviewed as well, with a review of some of the lessons learned while providing care in a deployed setting. Utilization of the knowledge learned in Iraq and Afghanistan, which have improved casualty care of deployed service members, can be used both in future military conflicts and in civilian trauma care.

Applied anatomy of the anterior cranial fossa: what can fracture patterns tell us?

The skull base is uniquely placed to absorb anteriorly directed forces imparted either via the midfacial skeleton or cranial vault. A variety of skull base fracture classifications exist. Less well understood, however, is fracture extension beyond the anterior cranial fossa (ACF) into the middle and posterior cranial fossae. The cases of 81 patients from two UK major trauma centres were studied to examine the distribution of fractures across the skull base and any relationship between the vector of force and extent of skull base injury. It was found that predominantly lateral force to the craniofacial skeleton produced a fracture that propagated beyond the ACF into the middle cranial fossa in 77.4% of cases, significantly more (P<0.001) than for predominantly anterior force (12.0%). Fractures were significantly more likely to propagate into the posterior fossa with a lateral vector of impact compared to an anterior vector (P=0.049). This difference in energy transfer across the skull base may, in part, be explained by the local anatomy. The more delicate central ACF acts as a 'crumple zone' in order to absorb force. Conversely, no collapsible interface exists in the lateral aspect of the ACF, thus the lateral ACF behaves like a 'buttress', resulting in increased energy transfer.