Surgical Neurology 63 (2005) 559 – 564

www.surgicalneurology-online.com
Trauma

Severe craniofacial fractures with frontobasal involvement and

cerebrospinal fluid fistula: indications for surgical repair
Giovanni Rocchi, MDa, Emanuela Caroli, MDa,*, Evaristo Belli, MDb, Maurizio Salvati, MDc,
Marco Cimatti, MDa, Roberto Delfini, MDa
Departments of aNeurological Sciences, Neurosurgery, and bMaxillofacial Surgery, University of Rome, bLa SapienzaQ, Italy
c
Department of Neurosurgery, INM Neuromed IRCCS, Pozzilli, Italy
Received 28 June 2004; accepted 22 July 2004

Abstract Background: The management of posttraumatic cerebrospinal fluid (CSF) fistulae is a controversial
topic. Although recent literature shows that endoscopic repair of CSF fistula is efficacious and
minimally invasive, in specific conditions open operative approach remains imperative.
Methods: A series of 36 patients underwent surgery for posttraumatic CSF fistula according to
specific selection criteria. These criteria included: bone displacement more than 1 cm (5 cases),
location of fracture in proximity to the midline (6 cases), involvement of cribriform plate (12 cases),
presence of encephalocele (3 cases), and failure of the conservative treatment (10 cases).The dural
defect was closed using vascularized pericranium and fibrin glue. Closure of the basal bone defect
was necessary in very large fractures or in special localization of the fistula, such as near the optic
nerve. Mean clinical follow-up was 5.7 years.
Results: Two patients presented meningitis without sequelae, and 12 with hyposmia. One patient
died of the severity of the primary brain injury and associated extracranial lesions. None of the
patients had recurrence.
Conclusions: Our results indicate that surgical dural repair in selected cases is related to low
morbidity and mortality preserving from delayed risks such as recurrence and infections.
D 2005 Elsevier Inc. All rights reserved.
Keywords: Cerebrospinal fluid fistula; Fracture; Head injury; Management; Meningitis; Rhinorrhea; Surgical repair

1. Introduction are specific conditions in which open operative approach is

mandatory.
About 80% of all cerebrospinal fluid (CSF) fistulae
The goal of this study is to assess the efficacy of our
result from head injuries with skull base fractures [26,42].
protocol that has been applied on a selected group of 36
Spontaneous fistulae are only 3% to 4% of all CSF
patients affected by posttraumatic CSF fistula.
fistulae and iatrogenic ones are about 16%, a result of
operations within the nasal and paranasal cavities and the
skull base [26].
Dandy [9] reported in 1926 the first successful dural 2. Materials and methods
repair of CSF fistula. At present, management of posttrau-
Between January 1997 and December 2000, 58 patients
matic CSF fistulae remains a controversial topic.
with cerebrospinal fistulae by anterior skull base fractures
Although recent literature shows that endoscopic repair
were admitted to our Institution. Of these 58 patients, 36
of CSF fistula is efficacious and minimally invasive, there
were surgically treated, whereas the remainder were treated
* Corresponding author. Via Meropia, 85-00147 Roma, Italy. Tel.: +39
successfully with conservative management.
06 4991 4484; fax: +39 06 47888054. The group of 36 patients surgically treated is the object of
E-mail address: manucarol2000@yahoo.it (E. Caroli). this study.
0090-3019/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.surneu.2004.07.047
560 G. Rocchi et al. / Surgical Neurology 63 (2005) 559–564
There were 29 men and 7 women. Age ranged between
16 and 62 years (mean, 38 years).
All patients had clinical history of head trauma; this was
classified on the basis of Glasgow Coma Score as minor
(1 patient), moderate (19 patients), and severe (16 patients).
Traffic accidents were the most frequent cause of head
trauma.
Cerebrospinal fluid rhinorrhea occurred immediately
after trauma in 30 cases and in following days (1-5) in
6 cases.
Severe additional extracranial lesions were present in 7
patients. Associated intracranial lesions causing cerebral
compression are reported in Table 1. We have divided the
patients into 3 groups according to the surgical timing:
– Group A (18 patients): early surgical repair (emergency
operative intervention or within 5 days from trauma );
– Group B (10 patients): surgical repair 8 days after
trauma;
– Group C (8 patients): surgical treatment from 12 to 25
days after trauma.
Early operation was performed in patients with com-
pressive hematoma, open trauma, severe bone derangement,
and severe CSF discharge. Delayed operation was performed
in 10 patients (group B) to attempt conservative treatment,
and in 8 patients (group C) to await the stabilization of the
vegetative parameters and the regression of the cerebral
edema. Conservative treatment for patients in group B
consisted of bed rest, continuous CSF lumbar diversion for
5 to 7 days, and carbonic anhydrase inhibitor administra-
tion. We used the same treatment for group B in patients of
group C before surgery, but CSF diversion was not applied
in patients with hypertensive pathology.
All patients were studied by fine-slice computed tomog-
raphy (CT) with multiplanar reconstructions and bone
window. Twenty-six patents had magnetic resonance imag-
ing (MRI) and 8 had CT cisternography. Four patients had
a fracture of posterior wall of the frontal sinus, the remain-
der presented with craniofacial fractures. Antibiotic prophy-
laxis (piperacillin, amikacin, and antibiotics on the basis
of the antibiogram from nasal tampon) was administered
in all patients.
The osteodural repairs were performed via craniotomy in
all 36 patients. In all cases the dural defect was closed using
vascularized pericranium. Fibrin glue was used routinely on
Table 1
Associated lesions in the 3 groups of our series
AL H BC P DBE PI ONC
Group A 9 6 4 2
Group B 3 2
Group C 5 6
Total 9 9 4 7 6 2
AL indicates associated lesions; H, cerebral hematoma; BC, brain
contusion; DBE, diffuse brain edema; PI, penetrating injury; ONC, optic
nerve compression; AEL, associated extracranial lesions.
Table 2
Surgical approaches in our series
Surgical approach No. of patients
Frontobasal bilateral 20
Frontobasal lateral 12
Transfrontal sinus 2
Frontonasal 2
dural suture. All patients had CSF diversion for 5 to 6 days
postoperatively.
The closure of the basal bone defect was necessary in
very large fractures or in particular location of the fistula,
such as near the optic nerve.
Surgical approaches used are described in Table 2. In
several patients we used the fracture line to design the limit
of the craniotomy.
3. Results
In all patients surgically treated the first dural repair was
successful. Meningitis without sequelae was observed in 2
cases of group C. One patient died 22 days after operation
because of the severity of the primary brain injury and
associated extracranial lesions.
Serial clinical examinations were performed to follow all
patients. Follow-up ranged from 4 to 7 years (mean, 5.7
years). None of the patients treated with surgery had
recurrence. Twelve patients with fracture involving cribri-
form plate presented with hyposmia. In these 12 cases,
impairment of the sense of smell occurred since the trauma.
In 22 of the 32 patients treated conservatively, CSF
leakage ceased within 1 week. These patients were dis-
charged neurologically intact, except for impaired sense of
smell present in 3 of them. In 10 patients, conservative
management failed and they were successively submitted
to surgery.
Five out of the 22 patients treated conservatively were
readmitted for meningitis, recurrent rhinorrhea, or both.
Four patients had recurrent CSF leakage from 3 to 19
months after discharge. Three of these patients developed
bacterial meningitis. In 1 patient with meningitis, spinal
arachnoiditis, responsible for the formation of multiple
compressive arachnoid cysts, occurred. One patient had
only meningitis.
4. Discussion
Cerebrospinal fluid fistulae have always been a diagnos-
Severe AEL
tic and therapeutic challenge.
The selection of patients who do or do not require
7
surgical treatment, timing of surgery, and antibiotic prophy-
7 laxis are questions widely debated in the neurosurgical
literature. Most neurosurgeons do not follow the advice of
Loew et al [25] and Cairns [6] that all CSF fistulae should
be treated surgically as soon as possible [18,26], but
 G. Rocchi et al. / Surgical Neurology 63 (2005) 559–564
suggest initial conservative treatment. The rationale of this
suggestion is based on the observation that 50% to 85% of
traumatic CSF fistulae occurring within 48 hours after
injury cease spontaneously [18,20,23,32,38,40,41]. How-
ever, spontaneous cessation of CSF leakage does not
guarantee that the dural tear is definitely sealed [12-15,24,25]
and recurrent rhinorrhea or late intracranial infections may
develop [12,14,15,24,25,31]. Delayed or recurrent CSF
rhinorrhea almost never stops without operative treatment
[26,41] and the risk of meningitis becomes high
[20,31,32,41].
On the basis of our experience, we think that the
conservative management of CSF fistulae consisting of
continuous lumbar drainage, bed rest, carbonic anhydrase
inhibitor administration, and antibiotic prophylaxis is an
excellent therapeutic option only in selected cases.
The flow chart shown in Fig. 1 shows our treatment
strategy of posttraumatic CSF fistulae. We agree with Jennet
et al [20] who pointed out that repair of a basal dural tear
rather than the treatment of a CSF leak should be the
concern of the neurosurgeon.
Fig. 1. Algorithm suggested for posttraumatic CSF fistula management.
561
This is supported by recent studies showing that if a
dural repair is undertaken, the risk of meningitis occurring
within 10 years is reduced from 85% to 7% [12,13,35].
The presence of specific kinds of fractures, evi-
dence of encephalocele or meningocele, and persistence
of rhinorrhea are useful parameters to select patients
for surgery.
– Compound, comminuted, depressed, or largely extended
craniofacial fractures require a surgical repair because
they do not heal spontaneously and are associated with
high risk of infections [4,8,34]. In this event, the CSF
fistula should be closed at the same operation. Sakas et
al [34] reported that size and location of anterior cranial
base fractures are predisposing factors to intracranial
infection, independently by the presence of rhinorrhea.
These authors indicate that fracture displacement, more
than 1 cm, and location in proximity to the midline have
high risk of infection. This risk increases when these
variables are combined and when the fracture occurs in
locus minoris resistentiae such as the cribriform plate
562 G. Rocchi et al. / Surgical Neurology 63 (2005) 559–564
that is thin and covered only by an arachnoidal layer,
without dural investment [30,34].
– Presence of encephalocele or meningocele is associated
with high risk of recurring meningitis (arising from sinus
bacteria). Also, because the herniated brain into osteo-
dural defect keeps the defect open, the natural healing of
the dural defect is prevented. For these reasons, ence-
phalocele or meningocele indicates the absolute need for
dural repair, even if CSF leakage is not observed.
– When rhinorrhea persists for more than 8 days, it should
be treated surgically [26,34] even in cases with small
fracture because spontaneous resolution is not likely and
the risk of meningitis is cumulative [1,7,12,13,
19,26,34,39]. In a long-term analysis of 160 cases of
traumatic CSF leaks, Eljamel and Foy [13] reported an
overall risk of meningitis before surgical repair of 30.6%
and a cumulative risk of 1.3% for day in the first and
second week, of 7.4% for week into the first month, and
exceeding 85% at 10 years of follow-up.
Sakas et al [34] included prolonged rhinorrhea (lasting
N 8 days) among the variables with cumulative effect
inducing a high long-term risk of posttraumatic meningitis.
Our choice of the surgery timing depends mainly on the
conditions of the patient and the presence of some sequelae
of the trauma such as intracranial hematomas, severe
pneumocephalus, or brain edema.
We prefer to perform a surgical repair as soon as the patient
is fit for surgery because of the well-known cumulative risk of
meningitis. When a severe cerebral hematoma, an open
craniocerebral trauma, or an expansive pneumocephalus
requires an early operation, we close CSF fistula at the same
time. In patients with severe brain edema, surgical closure of
a dural tear should be delayed until the edema has subsided
because cerebral parenchyma is more vulnerable and an
early operation could be fatal. We have postponed for 12 to
25 days 8 cases presenting with severe edema and in this
group morbidity and mortality were zero. The timing of
surgery in these cases is different for each patient.
Accurate identification of the leak site is related with the
surgical success above all if minimally invasive surgical
techniques are planned [37,42]. Plain skull radiography,
pluridirectional tomography, intraoperative injection of
fluorescin dye, positive contrast (iophendylate) studies,
and radioisotope cisternography have been proposed for
the detection of CSF fistula, but their usefulness is limited
[2,3,11,22,36,37]. More recently, MRI has been evaluated
and is shown to be a sensitive technique to localize CSF
leaks even in patients with inactive CSF fistulae [15,28].
Here, the recommendation of some authors is to perform
MRI not only for detecting the CSF leakage, but also to
determine if a fistula spontaneously closed [15]. Fine-slice
CT is superior to MRI in showing the bony defect; therefore,
these methods of investigation are complementary [15,28].
Computed tomography cisternography is considered the
best diagnostic method to diagnose the CSF fistulae
[2,5,10,16,17,27,29,42,43], but it is an invasive technique
[2,5,10,27-29,37,42,43]. Therefore, we perform it only if the
MRI or fine-slice CT is negative.
Surgical CSF leak repair may be performed transcranially
or extracranially. Transcranial approaches include the
traditional frontal craniotomy described by Dandy [9] in
1926, transnasal approach with cranialization of the frontal
sinus, and suprasinus transfrontal approach with lateral
extension if it is necessary to achieve posterior regions
(ie, in ethmoido-sphenoidal fractures).
The infection rate related to the transinus approach is
low, less than 2% according to Ray [33], 1% to 2% for
Talamonti et al [41], and 0% for Al-Mefty [4] and in our
experience. Extracranial approach may be achieved through
ethmoidectomy, frontal sinusotomy, and transnasally with
microscopic or endoscopic visualization. The extracranial
closure of CSF leak has evolved considerably with the
advent of the endoscopic techniques, but their use is limited
to specific cases such as small tear with precise localization
and without associated brain injuries. In such cases, the
endoscopic procedure is a good alternative to the anterior
transcranial approaches. In our series the presence of large
bone defect with herniation of the brain, massive CSF
rhinorrhea, open trauma, severe intracranial hematomas, or
destruction of the paranasal sinuses made the craniotomy
the only possible procedure.
The only case of death in our series was due to severe
primary brain injury and associated systemic lesions. On the
basis of our experience we can conclude that the intracranial
approaches are associated with low morbidity and mortality
and definitive closure of the osteodural leak in severe
craniofacial injuries. The time for surgery should be tailored
to the specific conditions of each patient.
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Commentary
I have read with interest the paper by doctors Rocchi et
al. Although their series is small, I agree in general with
their overall conclusions and with much of their algorithm
for management of established CSF fistulae. But I have, in
the past, been personally surprised by the spontaneous
resolution of an encephalocele. I would also comment that,
although persistent CSF fistulae should certainly be treated,
all patients with median or paramedian fractures certainly do
not require treatment.
C. David Hunt, MD
Maimonides Medical Center
Brooklyn, NY 11219, USA
The authors present a series of patients with posttrau-
matic dural fistulae that have been managed both conser-
vatively and surgically.
As the authors point out in their thoughtful discussion,
the management of dural fistulae is controversial with
accepted practices varying significantly between different
countries. There is no good evidence supporting many of
our common practices (such as prophylactic antibiotic use).
Although this is a relatively small series, a number of
important points have been identified by the authors. Firstly,
and most importantly, they have identified a relatively high
risk of meningitis associated with the dural fistulae. Even in
those patients who were treated conservatively on a
temporary basis while awaiting progression of cerebral
edema or vegetative parameters (group C) 2 of 8 patients
developed meningitis.