Transcranial penetrating skull base trauma with metal rod: Endoscopic repair of CSF leak

Penetrating skull base injuries are complex clinical scenarios requiring multidisciplinary management to address both immediate life-threatening conditions and long-term complications.Anterior skull base fractures account for 21% of skull fractures from which 4% were caused by head trauma [1]. Post-traumatic cerebrospinal fluid (CSF) leaks may arise, becoming a major source of morbidity; these can lead to the development of severe intracranial infections [2]. Endoscopic Endonasal Approach is a conservative technique that uses a multilayer coverage including a nasoseptal flap to create durable reconstruction [3]. We describe our experience using this technique to repair a wide anterior skull defect after extraction of a foreign body.

A 46-year-old male experienced a traumatic CSF leak following a penetrating head injury from a fall at a construction site, where a steel bar penetrated from the left temporo-mandibular juntction through the sphenoid sinuses to the right eye socket. Initial brain involvement was minimal, and the injury was isolated to the head.

This case highlights the complexities of managing penetrating brain injuries. Prior to deciding the extraction of the foreign body and subsequent endoscopic repair of the skull base, the multidisciplinary team relied on imaging for a secure removal. Maintaining airway, stabilizing the patient, and executing skilled surgical intervention were key to successfully manage the case. Postoperative treatment was crucial, including monitoring for complications such as diabetes insipidus and ensuring the closure of the CSF leak through endoscopic techniques. The integration of fluorescein in CSF during surgery allowed us to localize leaks effectively. This case highlights the importance of a well-coordinated medical response to assess patient management in severe traumatic scenarios. Lessons learned from such cases contribute significantly to the evolving field of trauma surgery, emphasizing the need for a structured approach to both acute and postoperative care.