Basilar Skull Fractures and Their Complications in Patients With Traumatic Brain Injury

Abstract

Objective

Since traumatic brain injury is more common in young people, who are the main workforce and builders of society, it is important to consider the effects caused by brain injury on them. In this study, we investigated the clinical manifestations, complications, and prognosis of patients with basilar skull fractures.

Methods

This cross-sectional study was conducted from March 2021 to March 2022 at the Kashani Hospital, Esfahan, Iran. Patients with basilar skull fractures were included in this study by census for one year. Recorded patient information was divided into two parts: demographic information, including age and sex, and disease information including loss of consciousness, signs of meningitis, need for surgery, and neurologic examination.

Results

In this study, 100 patients were included, of whom 89 were men. The most common complication was pain at the site of the trauma, followed by bruising and bleeding from the site of the trauma. Raccoon eyes and cerebrospinal fluid leakage were observed in 19% and 32% of the patients, respectively.

Conclusion

As the occurrence of trauma has an economic burden on the country's health system, we must identify its consequences and problems and prevent its occurrence as much as possible by implementing educational measures.

INTRODUCTION

Basilar skull fractures (BSFs) refer to fractures in the floor of the anterior, middle, or posterior cranial cavity that are caused by a local direct force mechanism.⁵⁾ With the increasing incidence of head injuries due to traffic accidents and subsequent deaths in severe cases, much more emphasis is placed on the diagnosis of extradural hematoma, subdural hematoma, intracerebral hematoma, fractures, and other head injuries such as BSF clinically or radiologically.¹,⁶⁾

Although most BSF are considered minor in nature, if diagnosed late, they can lead to debilitating complications, such as neurovascular injury, cerebrospinal fluid (CSF) leakage, meningitis, and even death if they are severe or accompanied with intracranial hemorrhage.¹³⁾ Trauma-related BSF are prone to CSF leakage and CSF fistula, which is the most common complication.¹⁰⁾ A patient with a CSF fistula is more likely to develop meningitis and may require surgery.¹¹⁾

BSF are associated with other central nervous system injuries in at least 50% of cases, and approximately 10% of cervical spine fractures.¹⁴⁾ BSF are also often associated with facial fractures, and their reported incidence with the number of facial fractures is as follows: one facial fracture (21.0%), two facial fractures (30.4%), three or more facial fractures (33.3%), bone fractures (8%–40%), and frontal sinus fractures (15%–20%).¹²⁾

Identification of the etiology and causes of BSF is helpful in preventing and reducing the incidence of injury and is effective for faster diagnosis, better treatment, and shorter length of hospital stay.⁸⁾ Finally, the identification of long-term complications and prognosis of these patients is effective in preventing long-term consequences; therefore, the present study aimed to determine the clinical manifestations, complications, and prognosis of patients with BSF.

MATERIALS AND METHODS

This cross-sectional study was conducted from March 2021 to March 2022 at Kashani Hospital, the main referral center for trauma victims in Isfahan Province, Iran. All patients with evidence of skull fractures based on computed tomography (CT) scans of the anterior, middle, or posterior cranial cavity were included in this study. The exclusion criterion was the absence of 10% of the required information in patients’ files. Written informed consent was obtained from all the patients or their companions (for unconscious cases). A total of 100 patients with BSF were examined in this study (FIGURE 1).

FIGURE 1. Presents patient selection flow chart.

Once the patients with head trauma were admitted to the emergency department, they underwent triage and received primary aid and resuscitation. After conducting the primary survey, the cervical spine was stabilized with a collar, and the patients with loss of consciousness (Glasgow Coma Scale score <8) underwent intubation. Patients who were hemodynamically unstable were treated, and brain CT scans, other necessary radiography, and consultations were performed.

Medical records were reviewed to collect patient information. Data were recorded on a checklist divided into two parts: demographic information, including age and sex, and injury mechanism and information on diseases, including loss of consciousness, pain, bleeding from the site of injury, epistaxis, CSF leak, meningitis signs, need for operation, and neurologic examination (level of consciousness; pupil size; cranial nerve; and signs of BSF, such as raccoon eyes and Battle’s sign).

Data were collected as a checklist using SPSS software version 22 (IBM Corp., Armonk, NY, USA) and analyzed, with the significance level set at p<0.05. The results are presented as frequency (percentage) or mean ± standard deviation (SD). The means of the variables were compared using an independent t-test and χ² test .

Ethics approval

All procedures were performed according to the ethical standards of the institutional and/or national research committee and the 1964 Helsinki Declaration and later amendments or comparable ethical standards. The neurosurgery department board members of Isfahan University supervised and approved this report on behalf of the Ethical Committee of Isfahan University of Medical Sciences (IR.MUI.MED.REC.1399.1185). The study was approved by the Isfahan University of Medical Sciences, Isfahan, Iran (code number IR. MUI. MED. REC.1400.058).

Informed written consent was obtained from all the patients. We declare that the manuscript complies with all instructions to the authors, authorship requirements have been met, and the final manuscript was approved by all authors. This manuscript has not been published elsewhere and is not under consideration by another journal. All the authors have accepted the manuscript to be submitted in this form to the journal.

RESULTS

TABLE 1 presents the demographic characteristics of the patients based on age classification.

TABLE 1. The patients’ demographic characteristics.

Variables	Age range (years)
	20<	20–40	40–60	60>	Total (n)
Total	37	28	23	12	100
Male/Female (sex ratio)	32/5 (6.4)	25/3 (8.3)	21/2 (10.5)	11/1 (11)	89/11 (8)
Hospital stays (day)	3.9±2.6	4.6±3.7	4±2.3	4.9±3.8	4.2±3

To evaluate the patients, they were divided into four groups as follows: <20 years (n=37), 20–40 years (n=28), 40–60 years (n=23), and >60 years (n=12). The results revealed that the mean ± SD of the patients' age was 32.20±15.77 years, and the mean length of hospital stay was 4.27±3.08 days (TABLE 1). A total of 89 patients were men, and 11 were women. A preponderance of male patients compared with female patients was observed in all the age groups. No significant differences in sex and length of hospital stay were observed between the age groups. In addition, no significant association was identified between sex and the outcomes of our cases.

TABLE 2 presents the complications of BSF according to age range. Among the patients, two had diffuse brain injuries and 19% had raccoon eyes. A significant association between cerebral edema and the need for surgery (p=0.001(was observed. However, no significant association was identified between CSF leakage and meningitis.

TABLE 2. Complications of basilar skull fracture based on age range.

Complication		Age range (years)
		20<	20–40	40–60	60>	Total (n)
Epistaxis		15	13	10	2	40
Raccoon eyes		4	6	5	4	19
CSF leak		9	10	11	2	32
Pneumocephalus		14	10	11	4	39
Facial nerve injury		15	13	13	4	45
Meningitis		2	0	1	1	4
Spinal cord injury
	Cervical	7	5	4	1	17
	Lumbar	0	0	0	1	1
	Thoracic	0	0	1	0	1
Epidural hematoma		6	3	6	3	18
Cerebral contusion		6	4	6	1	17
Subdural hematoma		6	1	3	4	14
Subarachnoid hemorrhage		8	3	6	2	19
Cerebral edema		2	0	1	0	3
Location of basilar fracture
	Anterior	21	13	12	8	54
	Middle	11	12	8	1	32
	Posterior	5	3	3	3	14
Surgery		10	5	7	1	23
Mortality		2	1	3	1	7

CSF: cerebrospinal fluid.

All the deceased patients were men. Motor vehicle crashes were the most frequent cause of death, and 85% of the deceased patients died of traffic accidents. CSF leakage was present in 85% of the deaths. All the patients who died had at least one cerebral hematoma. The mean age of the deceased patients was 37.7±19.7 years. The average length of hospital stay of the deceased patients was 4.14±4.59 days.

FIGURE 2 presents two examples of BSF.

FIGURE 2. Two examples of skull base fracture. (A) Brain CT scan of a 2-year-old girl who fell from a height of 2 meters. Fractures of the edge of the orbit bone (1) and the raccoon eye (2) are evident. (B) Brain CT scan of a 60-year-old man, who was injured in a pedestrian-car accident. Frontal contusion (3) and pneumocephalus (4) are evident.

CT: computed tomography.

TABLE 3 presents the frequency of injury mechanisms and their consequences.

TABLE 3. Frequency of the injury mechanism and its consequences.

Variables		Age range (years)
		20<	20–40	40–60	60>	Total (n)
Damage mechanisms
	Motor/Car accident	11/3	4/4	7/1	3/0	25/8
	MTCA	4	8	6	2	20
	CTPA	6	3	3	0	12
	Falling	7	3	4	3	17
	Assault	3	3	0	0	6
	CTCA	2	2	1	0	5
	MTPA	1	1	1	4	7
GCS (Mean±SD)		13.43±3.08	14.21±1.77	13.30±3.58	13.5±3.45	13.63±2.93

CTPA: car to pedestrian accident, MTCA: motor to car accident, CTCA: car to car accident, MTPA: motor to pedestrian accident, GCS: Glasgow Coma Scale.

According to TABLE 3, seven patients died, and 23 required surgery. The most common mechanisms of injury were motorcycle accidents (25 cases) and motor-to-car accidents (20 cases).

DISCUSSION

In this study, we evaluated the data of 100 patients with BSF from September 2020 to September 2021. Our results indicated that BSF caused different clinical manifestations, such as damage to vessels or nerves and fractures of different bones.

The reported incidence of BSF varies considerably between studies.²⁾ In this respect, 4% of all patients with severe head injuries suffer from BSF, accounting for 19–21% of skull fractures.⁷⁾ The incidence of these fractures was 3.5–24% in Asian studies, while previous studies in Nigeria indicated a higher incidence of 33–46%.⁹⁾

According to our results, men outnumbered women, in accordance with previous reports from India,¹⁴⁾ Brazil,¹²⁾ and Israel.¹⁵⁾ This finding may be attributed to more men using vehicles than women.

Based on our findings, most of our patients were affected by vehicle accidents. Bhaksar el al.²⁾ in a study conducted in India have reported that among 174 cases, 79.3% were affected by road traffic accidents. Joosse et al.³⁾ in a study conducted in Netherlands have reported that out of 49 individuals, 72% were injured by road traffic accidents.

Of all our patients, 23% received surgery. This is supported by Bhaksar et al.,²⁾ who have reported that 26.44% of their patients received surgery.

One of the most important complications identified in this study was CSF leakage, which occurred in 32% of the victims. In a study conducted in Florida, this complication was apparent in 45% of the patients, which was lower than the rate reported in our study.⁷⁾ Furthermore, in other studies conducted in Israel and the United States, 15% and 20% of the patients had CSF leakage, respectively.⁴,¹⁵⁾

Meningitis was another important complication observed in 4% of our cases; this is in consistent with the results (5%) obtained by Simon et al.¹⁰⁾

Among all the patients in our study, 7% died. Bhaksar et al.²⁾ have reported a higher mortality rate (10.34%).

Among the patients in our study, 19% had raccoon eyes and received surgery more than the others did (p=0.008, odds ratio=1.32). In a study conducted in Brazil, raccoon eyes and Battle’s sign were positively correlated with the severity of injury. These clinical signs should be regarded as alarm signs.¹²⁾ Our study however had some limitations, such as the incomplete data from the medical records.

CONCLUSION

BSF affect young people the most, who are the main workforce in society. Therefore, the government should implement preventative measures with the involvement of the entire nation and different organizations to decrease the burden of such events. Moreover, people via social media should be encouraged to wear helmets and use seatbelts while driving.