Early Endoscopic Repair of Traumatic Skull Base Dural Injuries: Challenging the Dogma of Conservative Management

Traditional management of traumatic skull base dural injury has often favored observation and conservative therapy, despite the risk of delayed intracranial complications. This paradigm originated when operative intervention required craniotomy and carried significant morbidity. The objectives of this study were to evaluate outcomes of early endoscopic repair for traumatic skull base dural injury and to assess whether radiographic evidence of dural violation, including pneumocephalus, may support consideration of early intervention.

A retrospective review was performed of 385 patients with traumatic skull base injury and evidence of dural disruption. Patients with congenital, spontaneous, or neoplastic etiologies were excluded. Endoscopic repair was performed in all patients with clinical or radiographic evidence of dural violation, including pneumocephalus, regardless of the presence of overt cerebrospinal fluid (CSF) leak. Outcomes, prior management, and complications were analyzed.

Among 385 patients, 219 (56.9%) presented with CSF leak and 254 (66.0%) with pneumocephalus. The ethmoid (244), frontal (212), and sphenoid (157) sinuses were most involved. Primary endoscopic repair success was achieved in 97.4% (375/385), increasing to 99.0% (381/385) following endoscopic revision. One hundred and two patients had prior conservative management, with 34 (33.3%) developing meningitis or intracerebral infection. Patients requiring multiple interventions were predominantly those with penetrating trauma.

Early endoscopic repair was highly effective for traumatic skull base dural violation. Pneumocephalus should be recognized as an important marker of dural disruption, even without overt CSF leak, and may justify early definitive repair in selected patients. Morbidity after conservative management supports reconsideration of observation-based algorithms.