What are the symptoms and treatment options for a patient with a base of skull fracture?

Base of Skull Fracture: Clinical Presentation and Management

Base of skull fractures present with characteristic clinical signs including CSF rhinorrhea/otorrhea, Battle's sign (retroauricular ecchymosis), raccoon eyes (periorbital ecchymosis), hemotympanum, and cranial nerve deficits, with management ranging from conservative observation for uncomplicated fractures to urgent surgical intervention for associated complications like significant hematomas or CSF leaks. 1, 2

Clinical Symptoms and Signs

Classic Physical Examination Findings

• Periorbital ecchymosis ("raccoon eyes") develops in anterior skull base fractures, typically appearing hours after injury 1, 2
• Battle's sign (retroauricular ecchymosis) indicates temporal bone or posterior skull base involvement, usually manifesting 12-24 hours post-injury 1, 2
• Hemotympanum suggests petrous temporal bone fracture with middle ear involvement 1, 3
• CSF rhinorrhea or otorrhea indicates dural tear with communication between intracranial space and external environment, creating meningitis risk 4, 2, 3

Neurological Manifestations

• Cranial nerve deficits are common, with anosmia (CN I), facial paralysis (CN VII), and hearing loss (CN VIII) being most frequent 2, 3
• Copious bleeding into the mouth from skull base fracture is an indication for immediate airway protection via intubation 5
• Focal neurological deficits including hemiparesis or pupillary abnormalities may indicate associated intracranial hematoma 6

Associated Complications

• Intracranial hematomas (epidural, subdural, or intracerebral) occur in significant proportion of skull base fractures 1, 6
• Vascular injuries to carotid or vertebral arteries can occur with fractures near major vessels 7, 8
• Meningitis risk is elevated even with linear nondisplaced fractures if dural tear is present 1, 4, 2

Diagnostic Approach

Immediate Imaging

• Non-contrast CT scan with both brain and bone windows is the first-line imaging modality for all suspected skull base fractures 7
• CT angiography should be obtained when fractures are near major vascular structures or if vascular injury is suspected 7, 8

Clinical Assessment Priorities

• Glasgow Coma Scale (GCS) score determines need for airway intervention, with GCS ≤8 requiring immediate intubation 5, 8
• Significantly deteriorating conscious level (fall in GCS of ≥2 points or motor score of ≥1 point) mandates intubation 5
• Loss of protective laryngeal reflexes necessitates airway protection 5

Treatment Algorithm

Indications for Immediate Surgical Intervention

• Open displaced skull fracture requires surgical debridement and closure 7, 6
• Closed displaced fracture with brain compression necessitates urgent decompression 7
• Significant underlying hematoma (particularly with mass effect or neurological deterioration) requires evacuation 7, 8, 6
• Persistent CSF leak after conservative management may require surgical repair 4, 3

Conservative Management Criteria

• Non-displaced or minimally displaced fractures without significant brain injury can be managed conservatively 7
• Absence of neurological deficits supports non-operative approach 7
• No evidence of dural tear or CSF leak allows for observation 7
• Small hematomas without mass effect in neurologically intact patients may be monitored 9

Airway Management in Severe Cases

• Immediate intubation is required for copious oral bleeding from skull base fracture 5
• Rapid sequence induction with manual in-line cervical spine stabilization should be performed in trauma patients 5
• Target blood pressure maintenance during intubation: systolic BP >110 mmHg and MAP >90 mmHg 5, 8

Physiological Targets During Transfer/Management

• PaCO2 should be maintained at 4.5-5.0 kPa to avoid cerebral vasoconstriction from hyperventilation 5, 8
• PaO2 ≥13 kPa ensures adequate cerebral oxygenation 5, 8
• Systolic blood pressure >110 mmHg and MAP >90 mmHg maintains cerebral perfusion pressure 5, 8

Surgical Techniques When Indicated

• Wide craniotomy covering the entire hematoma with preparation for decompressive craniectomy if brain swelling occurs 8
• Removal of bone fragments when necessary for displaced fractures 7
• Evacuation of associated hematomas is crucial 7, 8
• Duroplasty is required in 61% of compound elevated skull fractures 6

Post-Treatment Management

Monitoring Requirements

• Intracranial pressure (ICP) monitoring should be considered in severe cases with risk of intracranial hypertension 7, 8
• Target ICP <20-22 mmHg and cerebral perfusion pressure >60 mmHg 8
• Serial neurological examinations are essential as deterioration can occur hours to days after initial presentation 5

Complication Surveillance

• Infection monitoring for meningitis (27% incidence), brain abscess (11%), and surgical site infection is critical 6, 2
• CSF leak surveillance as persistent leaks predispose to meningitis and may require delayed surgical repair 4, 2, 3
• Seizure prophylaxis with levetiracetam should be considered in high-risk cases 5, 8

Long-Term Follow-Up

• Cranioplasty at approximately 3 months post-surgery if significant bone defect remains 7, 8
• Cranial nerve function assessment for persistent deficits requiring rehabilitation 2, 3

Critical Pitfalls to Avoid

• Never use hypotonic fluids (including Ringer's lactate) in skull base fractures with brain injury; use only 0.9% normal saline 8
• Do not delay neurosurgical consultation for large hematomas while "observing"—this increases mortality 8
• Avoid prophylactic hyperventilation as hypocapnia worsens cerebral ischemia 8
• Do not miss vascular injuries—obtain CT angiography when fractures are near major vessels 7, 8
• Recognize that normal initial CT does not exclude delayed deterioration—serial examinations are mandatory 5
• Do not discharge patients with skull base fractures without clear follow-up as complications can develop days to weeks later 5