Basilar Skull Fracture
Neurological, Trauma
Context
- Classic clinical exam findings should be considered a positive diagnosis
- High blunt force – 50% have another intracranial injury; 5-15% have C spine fracture
- Complications relatively rare but commonly missed
- associated with significant morbidity/mortality
- CT scan is positive in only ~50% cases (still the gold standard though)
- Adverse outcomes more common when CT positive
- Complications:
- CSF leak
- Hearing loss
- Cranial nerve palsy (entrapment > transection)
- Cerebrovascular injury (Carotid > Vertebral)
- Intracranial hemorrhage
- Pitfalls:
- Delayed development of clinical signs of complications (CSF leak, cranial nerve deficit, complications of carotid/vertebral artery injury routinely present later than 48 hours)
- Intracranial hemorrhage may develop/evolve over 12-24 hours
- Meningitis may further complicate CSF leak in up ~6%
- Carotid artery injury poorly correlated with presence of involvement of carotid canal
- Missed carotid artery injury associated with severe permanent neurologic deficit or mortality in up to 50%
Recommended Treatment
- No role for prophylactic antibiotics in CSF leak (Cochrane Review 2015)
- Patients with CSF leak should be followed up at 7 days to ensure resolution
- Suggest CT angiogram to check for cerebrovascular injury if:
a. CT evidence of basal skull fracture involving carotid canal OR
b. CT evidence of any basilar skull fracture AND:
i. Middle cranial fossa involvement (temporal/sphenoid bone)
ii. Any associated intracranial hemorrhage
iii. Pneumocephalus or sphenoid sinus air fluid level
c. Clinical or CT evidence of basilar skull fracture AND high-risk clinical features:
i. High force mechanism
ii. GCS < 6, Diffuse axonal injury
iii. Focal neurologic deficits, visual changes
Criteria For Hospital Admission
- Altered LOC
- Presence of non-surgical ICH or high-risk features (eg. high force, altered GCS/DAI, posterior fossa involvement, suspicion of vascular injury) requiring close observation/repeat/further imaging
- Cerebrovascular injury requiring observation/further management
- Factors preventing safe observation/discharge planning/adequate follow-up
- Suspicion of meningitis in context of known/suspected CSF leak
Criteria for Transfer to Neurosurgical Facility
- Surgical or high-risk ICH requiring Neurosurgical intervention
- Need for further imaging (CT scan, CT angiogram)
- Need for management or further assessment for complications:
- Cerebrovascular injury
- Suspected cranial nerve entrapment or transection
- CSF leak (especially if failed to resolve at 7 days)
Criteria For Close Observation And/or Consult
- CSF leak (consider consult to establish follow-up pathway)
- Cranial nerve deficit (consult to establish follow-up pathway)
- Proven or suspected cerebrovascular injury
- Non-surgical ICH (high-risk to establish need for transfer/admit/observe/repeat imaging)
- High-risk mechanism or involvement of middle or posterior cranial fossa (observe for 12-24 hours for delayed ICH)
Criteria For Safe Discharge Home
- Patient adequately assessed/imaged:
- CT/CT angiogram
- Cranial nerve examination including visual acuity
- C spine
- Clear return instructions for signs/symptoms of:
- Intracranial hemorrhage
- Visual change/loss
- Cranial nerve deficit
- CSF leak AND/OR signs/symptoms of meningitis
- Establishment of specialist follow-up for presence of CSF leak or cranial nerve deficit at time of discharge
- EP or GP reassessment at 7 days for reassessment for development of cranial nerve deficit, new or persistent CSF leak, signs/symptoms of cerebrovascular injury
Quality Of Evidence?
High
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
Moderate
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
Low
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Justification
Low to very low-level evidence for Admission/Transfer/Observation/Followup criteria – no established guidelines or large studies
Antibiotic prophylaxis in CSF leak = Medium (Cochrane systematic review showed trend toward benefit but confidence interval crosses 1 – likely more studies required). No current evidence to support.
Canadian CT head rule provides high-level evidence as to when to consider CT head in blunt head trauma.
Low-level evidence for CT angiogram criteria
Related Information
OTHER RELEVANT INFORMATION
Reference List
Relevant Resources
RESOURCE AUTHOR(S)
DISCLAIMER
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Apr 30, 2017
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