Basilar Skull Fractures
Adam R.D., Victor M., Ropper A.H. Principles of Neurology (8th ed).
Characteristic Clinical Signs :
- Fracture of the petrous pyramid deforms the external auditory canal or
tears the tympanic membrane leakage of CSF (otorrhea); or, blood may
collect behind an intact tympanic membrane.
- If the fracture extends more posteriorly damaging the sigmoid sinus
the tissue behind the ear and over the mastoid process becomes boggy
and discolored (Battle sign)
Adam R.D., Victor M., Ropper A.H. Principles of Neurology (8th ed).
Hemotympanum
Battle Sign
Characteristic Clinical Signs :
• Basal fracture of the anterior skull cause blood to leak into the
periorbital tissues, imparting a characteristic “raccoon” or “panda
bear” appearance.
• If the skin over a skull fracture is lacerated and the underlying
meninges are torn, or if the fracture passes through the inner wall of
a paranasal sinus bacteria may enter the cranial cavity, with
resulting meningitis or abscess formation.
• CSF that leaks into the sinus presents as a watery discharge from the
nose (CSF rhinorrhea)
Adam R.D., Victor M., Ropper A.H. Principles of Neurology (8th ed).
Racoon Eyes
halo or double-ring sign
Diagnosis
The initial evaluation is usually via a non-contrast computed
tomography (CT) scan.
Adam R.D., Victor M., Ropper A.H. Principles of Neurology (8th ed).
• CT scans through the base of
the skull may not show the
fracture itself, but fluid in the
sphenoid sinus (arrows)
Bradley’s Neurology in Clinical Practice.
Treatment
• Elevate head of bed to 30 degrees
• Respiratory goals: SaO2>90%, PaO2>60 mmHg, PCO235-45 mmHg
• Hemodynamic goals: SBP> 100 mmHg if 50-69 years old, SBP>110 if
15-49 years old or >70 years old
• SBP<90 mmHg risk factor for mortality in brain trauma
• Patients with basilar skull fractures require admission for
observation.
• Basilar skull fractures increase the risk of meningitis, prophylactic
antibiotics to prevent meningitis
Adam R.D., Victor M., Ropper A.H. Principles of Neurology (8th ed).
Diffuse axonal injury
Diffuse axonal injury is a very common severe head injury associated
with significant morbidity.
It is characterized clinically by rapid progression to coma in the absence
of specific focal lesions
Adam R.D., Victor M., Ropper A.H. Principles of Neurology (8th ed).
Etiology
- The most common etiology of diffuse axonal injury involves high-
speed motor vehicle accidents
- mechanism involves an accelerating and decelerating motion that
leads to shearing forces to the white matter tracts of the brain.
Adam R.D., Victor M., Ropper A.H. Principles of Neurology (8th ed).
• The Adams Diffuse Axonal Injury Classification:
• Grade 1: A mild diffuse axonal injury with microscopic white matter
changes in the cerebral cortex, corpus callosum, and brainstem
• Grade 2: A moderate diffuse axonal injury with gross focal lesions in
the corpus callosum
• Grade 3: A severe diffuse axonal injury with finding as Grade 2 and
additional focal lesions in the brainstem
Diagnosis
DAI is diagnosed after a traumatic brain injury with GCS less than 8 for
more than six consecutive hours.
- computed tomography (CT) head findings of small punctate
hemorrhages to white matter tracts can indicate diffuse axonal injury in
the setting of an appropriate clinical presentation.
- Currently, magnetic resonance imaging (MRI), specifically diffuse
tensor imaging (DTI), is the imaging modality of choice for diagnosis of
diffuse axonal injury
Bradley’s Neurology in Clinical Practice.
Bradley’s Neurology in Clinical Practice.
Treatment
• Initial treatment priority in traumatic brain injury is focused on
resuscitation.
• ICP monitoring is indicated in patients with GCS of less than 8 after
consultation with neurosurgery.
• Cerebral oxygen saturation monitoring can be used with ICP
monitoring to assess the degree of oxygenation.
• Ropper AH, Samuels MA, Klein JP, 2014. Adam’s and victor’s principles
of neurology. New York: McGraw-Hill Education.
• Biller J, Love BB, Schneck MJ, 2012. Bradley’s Neurology in Clinical
Practice. Philadelphia: Elsevier
• Fassil B. Mesfin; Nishant Gupta, 2020. Diffuse Axonal Injury. .
Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK448102/
• Leslie V. Simon; Edward J. Newton. 2020. Basilar Skull Fractures.
Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK470175/
