From the Guidelines
The management of a basal skull fracture should prioritize immediate brain and cervical computed tomography (CT) scan without delay, as well as maintaining a systolic blood pressure > 110 mmHg to prevent hypotension and ensure optimal cerebral perfusion pressure. This approach is based on the strongest evidence from the study published in Anaesthesia in 2018 1, which emphasizes the importance of prompt imaging and blood pressure management in patients with severe traumatic brain injury, including those with basal skull fractures.
Initial Management
The initial management of a basal skull fracture involves:
- Stabilization of the patient with airway protection, hemodynamic support, and neurological assessment
- Admission for close observation with regular neurological checks to detect any deterioration early
- Consideration of prophylactic antibiotics if there is cerebrospinal fluid (CSF) leakage, with options including amoxicillin-clavulanate or ceftriaxone for 7-10 days
Imaging and Monitoring
- A brain and cervical CT scan should be performed without delay to guide neurosurgical procedures and monitoring techniques 1
- Early exploration of the supra-aortic and intracranial arteries using CT-angiography is suggested in patients with risk factors, including fractures of the basal skull 1
- Follow-up imaging with CT scans may be necessary to monitor healing and detect any complications
Complication Prevention and Management
- Patients should avoid activities that increase intracranial pressure, such as nose blowing, straining, or heavy lifting
- Pain management typically involves acetaminophen and avoiding NSAIDs due to bleeding risk
- CSF leaks should be monitored, as most resolve spontaneously within 7-10 days, but persistent leaks may require neurosurgical intervention
- Neurosurgical consultation is essential, and complications like meningitis, CSF leaks, cranial nerve injuries, and vascular injuries require vigilant monitoring and prompt treatment.
From the Research
Management Plan for Basal Skull Fracture
The management plan for a basal skull fracture involves several key considerations, including:
- Diagnosis: High-resolution computed tomography (CT) head is the gold standard for detecting basal skull fractures 2
- Clinical signs: Raccoon eyes, CSF rhinorrhea, and other clinical signs can be supportive but not definitive for basal skull fractures 2
- CSF leak: Most cases of CSF leak can be managed conservatively, but leaks persisting more than 7-10 days have a high risk of developing meningitis and may require surgical intervention 2
Antibiotic Prophylaxis
The use of antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures is not supported by current evidence:
- A Cochrane review of five randomized controlled trials (RCTs) found no significant difference in the frequency of meningitis between antibiotic prophylaxis groups and control groups 3, 4
- The review also found no reported adverse effects of antibiotic administration, but one study reported an induced change in the posterior nasopharyngeal flora towards potentially more pathogenic organisms resistant to the antibiotic regimen used in prophylaxis 3, 4
Complications and Treatment
Basal skull fractures can be associated with critical complications, including:
- Meningitis: Can occur even in the absence of a CSF leak, and may require surgical dural repair in addition to antibiotic treatment 5
- CSF leakage: Can be managed conservatively in most cases, but may require surgical intervention if persistent 2
- Other complications: Such as ventriculitis, abscesses, and postmeningitis hydrocephalus, which may require surgical treatment and antibiotic therapy 5
Imaging and Diagnosis
Imaging findings and possible pitfalls in imaging of skull base trauma are important considerations in the management of basal skull fractures: