"High risk" anterior basal skull fractures. Surgical treatment of 64 consecutive cases

Anterior Basal Skull Fractures (ABSFs) may be complicated by Cerebrospinal Fluid (CSF) fistulae and intracranial infections. An initially non-operative management is usually suggested since most fistulae spontaneously stop within a few days thus requiring no surgical repair. However, if the fistula fails to stop or recurs, surgical treatment is to be considered. Furthermore, if the fracture is complicated by meningitis, there is a relative risk of recurring infections and surgical repair may be also considered. Finally, surgical repair may be suggested in cases of compound, comminuted, depressed, largely extended cranio-facial fractures (the so-called "fracas craniofaciaux") where spontaneous healing is considered unlikely and risk of infection is high. Accordingly we termed "high risk" fractures those associated with active (persistent or recurring) cerebrospinal fluid fistula, those with meningitis and the so-called "fracas craniofaciaux". In this paper, we report our personal experience in surgical treatment of 64 consecutive "high risk" anterior basal skull fractures. Thirty-seven patients had persistent or recurring fistulae, ten had intracranial infections and seventeen had severe bone derangement of the anterior skull base. The osteodural repairs were performed through bilateral or unilateral subfrontal approach. In 59 cases the initial procedure was successful whereas 4 patient needed additional surgery but were ultimately successfully treated. One patient died. No major permanent neurologic or neuropsychologic impairments were reported. On the basis of our experience, we think that intracranial repair is a very suitable treatment modality in facing "high risk" anterior basal skull fractures.