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Basal skull fractures are associated with mortality in pediatric severe traumatic brain injury
Insights
Basal skull fractures (BSFs) occur in 26% of pediatric severe traumatic brain injuries (sTBI). These fractures, particularly in the temporal bone, are linked to cerebrospinal fluid leaks and increased mortality risk in children.
Area of Science:
- Trauma Surgery
- Pediatric Neurosurgery
- Epidemiology
Background:
- Basal skull fractures (BSFs) result from blunt force trauma to cranial bones.
- Data on BSFs in pediatric severe traumatic brain injury (sTBI) is limited.
- This study investigates BSF prevalence, anatomy, and outcomes in pediatric sTBI.
Purpose of the Study:
- To determine the prevalence of basal skull fractures in pediatric patients with severe traumatic brain injury.
- To analyze the anatomical distribution of BSFs in this population.
- To assess the association between BSFs and short-term outcomes in pediatric sTBI.
Main Methods:
- Retrospective review of severely injured pediatric patients (age <18) with sTBI (GCS ≤8, AIS head ≥4).
- Neuroimaging analysis to identify skull fractures.
- Univariate and multivariate statistical analyses were performed.
Main Results:
- BSFs were present in 26% (47/180) of pediatric sTBI patients, with the temporal bone being most frequently fractured.
- 32% of BSF patients experienced cerebrospinal fluid leaks (e.g., otorrhea, rhinorrhea).
- BSFs were associated with increased mortality (OR 6.87), acute central diabetes insipidus, and longer hospital stays in survivors.
Conclusions:
- Basal skull fractures are prevalent in 26% of pediatric sTBI cases.
- The temporal bone is the most common site for BSFs in pediatric sTBI.
- BSFs are significant indicators of blunt force trauma and independent predictors of mortality in pediatric sTBI.
Background:
Basal skull fractures (BSFs) are caused by blunt force trauma, occurring in the temporal, occipital, sphenoid, and/or ethmoid bones. In pediatric severe traumatic brain injury (sTBI), there is a paucity of data on BSFs. Our goal was to investigate the BSF prevalence, anatomy, and association with short-term outcomes in pediatric sTBI.
Methods:
We retrospectively reviewed all severely injured (Injury Severity Score ≥12) pediatric patients (aged <18 years) admitted to our hospital after experiencing an sTBI (Glasgow Coma Scale score ≤8 and head Abbreviated Injury Scale score ≥4). Neuroimaging for all sTBI patients was reviewed for skull fractures. Data were analyzed with both univariate and multivariate techniques.
Results:
Of the 180 patients with sTBI, 47 had BSFs for a prevalence of 26% (69 BSFs in total; 16 sTBI patients had ≥2 BSFs). The squamous temporal bone was fractured most frequently (n=30/47 sTBI patients with BSFs). Patients with BSFs were heavier and had more facial injuries than those without (p < 0.05) but were similar in all other admission demographics, injury profiles, and clinical characteristics. Cerebrospinal fluid leak was found in 32% (n = 15 of 47) of BSF patients (otorrhea, n = 12; rhinorrhea, n = 1; otorrhea/rhinorrhea, n = 2; p < 0.001). Mortality, acute central diabetes insipidus, and fewer ventilator-free days were associated with BSFs (p < 0.005), whereas in sTBI survivors, BSFs were associated with longer lengths of stay (p < 0.05). Multiple logistic regression showed that BSFs were positively associated with the presence of subarachnoid hemorrhage (odds ratio [OR], 4.00; p = 0.001), contusion (OR, 2.48; p = 0.029), herniation (OR, 3.40; p = 0.037), and cerebral edema (OR, 2.30; p = 0.047) but negatively associated with diffuse axonal injury (OR, 0.20; p = 0.003). BSFs and mortality were strongly associated (OR, 6.87; p = 0.019).
Conclusion:
BSFs occurred in 26% of pediatric sTBI patients. The temporal bone was fractured in two thirds of sTBI patients with BSFs, and one third was associated with cerebrospinal fluid leaks. BSFs represent a significant linear blunt force and are independent predictors of mortality.
Level Of Evidence:
Prognostic and epidemiologic study, level III.
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