Skull Base Trauma Disclosures - Educational Symposia€¦ · Skull base trauma ! Up to 16% of CHI ! High velocity impact ! Penetrating trauma

Skull Base Trauma & CSF Leaks

ASHNR 2016

Department of Radiology and Imaging Sciences Division of Neuroradiology

Kristen Lloyd Baugnon, M.D.

Disclosures

No relevant disclosures

Objectives

!  Describe patterns of skull base fractures

!  Identify complications requiring

multidisciplinary treatment

!  Algorithim for CSF Leak Diagnosis and Evaluation

!  Develop a checklist

Skull base trauma

!  Up to 16% of CHI !  High velocity impact !  Penetrating trauma <10%

!  Assoc w complex facial and orbital fractures !  Detection important

!  Tx depends on IC injury and complications !  Multidisciplinary care

Detection of skull base fx !  Can be challenging if

nondisplaced !  NCCT Clues:

!  Pneumocephalus !  Blood in sinuses/mastoids !  Overlying ST swelling

!  Freq missed: Occipital condyle, ACF, tbone

Detection of skull base fx !  Thin section bone

algorithm MDCT with reformats !  Coronal, Sagittal, tbone !  3D VR reformats !  Curved MIP reformats

!  Beware of pseudofractures!

Supraorbital foramen and sphenofrontal suture

Suture diastasis Patterns of SB Fracture !  Patterns seen depend

on direction of impact !  Many different

classification systems !  Location in skull base

(ACF, MCF, tbone, PCF)

!  Assoc complications !  Fractures often

complex/mixed

Anterior cranial fossa trauma Anterior skull base fractures !  Direct frontal trauma !  “Frontobasal” fractures

!  Frontal (upper 1/3 face) !  Basal (ant skull base)

!  Type I-III fractures !  Type I – medial, linear !  Type II – lateral !  Type III – mixed,

comminuted

Type I Frontobasal fracture

Manson et al Plast Recon Surg 2009

Anterior skull base fractures !  Direct frontal trauma !  “Frontobasal” fractures



comminuted !  Types II& III more assoc with

complications

Type II Frontobasal fracture

Anterior skull base fractures !  Direct frontal trauma !  “Frontobasal” fractures



comminuted !  Types II& III more assoc with

complications

Type III Frontobasal fracture

Middle cranial fossa trauma Central skull base fractures !  Oblique pattern: frontal

impact extending to central skull base !  Facial fxs, type II/III FB

fxs, CSF leak !  Transverse: lat impact

!  CN and vascular injury !  Often assoc with tbone

fxs !  Anterior vs posterior Oblique central skull base fracture

Central skull base fractures !  Oblique pattern: frontal




fxs !  Anterior vs posterior

Anterior Transverse fx

Central skull base fractures !  Oblique pattern: frontal




fxs !  Anterior vs posterior

Posterior Transverse fx

Posterior skull base trauma Posterior skull base fractures

!  Lateral and/or posterior blow to occiput

!  Occipital bone, +/-ext to petrous t bone and FM

!  No simple classification scheme

!  T bone fxs described independently

Clivus fractures

Transverse Clival fx

!  Central and posterior skull base fractures

!  High mortality !  Brainstem, NV

!  Transverse !  Lateral blow !  CN/ICA injury (CN VI)

Clivus fractures

Transverse Clival fx




Clivus fractures

Longitudinal Clival fx




!  Longitudinal !  Axial loading !  VB/CC jxn injury, retroclival

hematoma

Clivus fractures

Longitudinal Clival fx




!  Longitudinal !  Axial loading !  VB/CC jxn injury, retroclival

hematoma

Complications of SB trauma

!  Depend on location !  Intracranial !  Vascular (MCF & PCF) !  CN

!  ACF: CN II (Anosmia) !  MCF: CN II, III, IV, V, VI !  Tbone: CN VII, VIII !  PCF: CN IX, X, XI, XII

!  CSF leak (ACF, MCF)

Intracranial injury !  IC injuries common – high

velocity impact !  Multicompartmental

hemorrhage, parenchymal contusions, DAI

Intracranial injury: MCF

Venous epidural hematoma

!  Anterior MCF epidural hematoma

!  Greater wing sphenoid fx !  Benign – venous

(sphenoparietal sinus) !  Self limited

Arterial epidural hematoma

!  Anterior MCF epidural hematoma

!  Greater wing sphenoid fx !  Benign – venous

(sphenoparietal sinus) !  Self limited

!  Lateral MCF epidural – middle meningeal artery

Intracranial injury: MCF

!  Posterior Fossa Epidural Hematoma (PFEDH)

!  Most common IC comp assoc with posterior skull base fx

!  Venous etiology !  Children !  Can expand rapidly !  May require

decompression

Intracranial injury: PCF Vascular Injury: Venous !  Traumatic venous sinus

thrombosis !  55% of fxs through

jugular bulb/sigmoid sinus

!  Transverse and sagittal sinus less common

!  ↑ ICP, venous hemorrhage, infarct (7%), dural AVF

Delgado AJE et al. Radiology 2010

!  Traumatic venous sinus thrombosis

!  55% of fxs through jugular bulb/sigmoid sinus



Non contrast head CT


Vascular Injury: Venous

!  Traumatic venous sinus thrombosis

!  55% of fxs through jugular bulb/sigmoid sinus



CTA/CTV


Vascular Injury: Venous

Traumatic dural venous sinus thrombosis vs extrinsic compression



Vascular injury - BCVI !  Common comp (8.5%)

!  MCF & PCF

!  ICA injuries !  York et al: Fractures through

carotid canal 35% PPV for ICA injury: 35% PPV !  Modified Denver criteria

!  CTA !  Stroke risk decreases with

anticoagulation !  Vertebrobasilar injuries

!  Clivus, occiput, occipital condyle

Vascular injury: CC Fistula !  Traumatic direct

connection btwn ICA and cav sinus !  High flow fistula

!  Exophthalmos, bruit, chemosis, vision loss, ophthalmoplegia

!  Acute or delayed !  DSA diagnostic &

therapeutic

Cranial Nerve Injury: ACF !  Anosmia (CN I) !  Overall incidence of 7%,

increased in ACF injuries !  Esp cribriform plate !  Frontal lobe contusions

!  CSF leak and repair !  Only 10% recover sense

of smell, often delayed

Cranial nerve injury: MCF !  Acute or delayed presentation

!  Delayed: Stretching/edema, better prognosis

!  Optic nerve canal: II !  SOF:III, IV, V1, VI

!  Orbital apex syndrome

!  Sella: bitemporal heminaopsia (chiasm)

!  Cav sinus/clivus: III, IV, V1, V2, VI

CN Injury: PCF

!  Jugular foramen: IX, X, XI !  Hypoglossal canal

(occipital condyle): XII

CSF Leak

!  10-30% of skull base fxs !  Comminuted fxs

!  Type II/III FB fxs, tegmen, sphenoid

!  Pneumocephalus !  CSF otorrhea & rhinorrhea

!  Often resolves spontaneously !  Surgery for persistent leak

!  Delayed presentation

Suspected CSF Leak !  Beta 2 transferrin (beta trace protein) assay

!  First screening test “gold standard” !  Protein specific to CSF !  Unequivocal evidence to support use

!  High sensitivity and specificity

!  Patient collects in testtube !  stores room temp or fridge

!  Requires only a few drops (0.5 -1 cc) !  Limitations:

!  Intermittent or no leak (unable to collect) !  False postive (rare!) Liver failure

Imaging evaluation !  Goals of imaging:

!  LOCALIZE the leak !  Characterize size of defect

!  Assess for meningocele !  Confirm diagnosis !  Assess for underlying cause

!  No definite imaging gold standard !  Difficult diagnosis !  Lacking randomized controlled trials !  CT/MRI/cisternography (NM, CT, MR)

HRCT !  Standard of care – first line !  Localize osseous defect (s): 95% Sensitivity !  Do not need active leak to see defect !  Images used for intraop guidance !  MDCT : Thin slices (< 1mm) with reformats

!  Image sinuses and mastoids !  Manipulate data on workstation, optimize W/L settings !  Measure defect in mutiple planes

!  Correlates with size of defect within 2 mm in 75% in one study

HRCT – Imaging findings

Osseous defect with fluid level in sinus or mastoid

Lloyd K, et al Radiology 2008

HRCT – Imaging findings !  Nondependent soft tissue in nasal cavity or ME cavity,

adj to bony defect !  Concerning for cephalocele !  Consider MRI

HRCT !  If only one defect, and positive B2 transferrin

!  Surgery

!  Limitations: !  Defect does not necessarily = leak !  Multiple osseous defects with adjacent sinus opac

42 yo F w remote h/o trauma

CT - cisternogram !  Pt needs to be actively leaking (or able to elicit) !  Technique:

!  Pre-Cisternogram CT: !  Supine MDCT with thin sections (reformats) !  Blood, inspissated secretions, osteogenesis

!  LP: 5-7 cc of intrathecal contrast !  Head down and provocative maneuvers

!  Post-Cisternogram CT: !  Direct coronal in prone position (elicit leak) !  Supine MDCT with thin section reformats

CT Cg - Findings !  Bony defect !  ↑ density adjacent to

bony defect (measure ROI if no visible change)

!  Pooling of high density in adjacent sinuses


CT cg findings

•  “Souffle” effect •  Contrast washout

•  Dependent drainage •  Mvmt with position

CTcg Findings ROI Measurement

Pre ROI = - 12 Post ROI = 69

CT-Cg Limitations !  Invasive

!  Small but inherent risk of infection/lumbar CSF leak !  Intrathecal contrast risk

!  Radiation !  Time intensive interpretation !  Limited usefulness in slow flow or intermittent

leaks

MR - Cg !  Noninvasive & nonionizing !  Indicated if suspected encephalocele

!  Nondependent soft tissue adjacent to bony defect !  Completely opacified sinus or ME (lobulated) adjacent

to bony defect !  Heavily T2w FS FSE sequences

!  High resolution 3D T2 w SSFP (GRE) sequences !  i.e. CISS, FIESTA, SPACE

!  Thin (3 mm) T1 axial, sag, coronal

!  Sensitivity (85-89%), best combined w HRCT

MR – Cg Imaging Findings !  Continuous column of T2

hyperintense CSF extending from SA space to extracranial soft tissues

!  Frank herniation of brain tissue


MR – Cg with IT Gad !  Promising studies

!  Sensitivity: up to 100% for high flow !  Selculuk et al: 60-70% sens for intermittent or

suspected leaks !  Delayed imaging up to 24 hours later

!  No ionizing radiation !  Ease of interpretation !  Improved contrast resolution !  Assess cephaloceles

MR – Cg with IT Gad - Limitations

!  Off label use, not FDA approved in US !  Many studies from outside US !  No unexpected adverse effects (HA, meningitis) with

doses and agents used (up to 107 pts in one study) !  No long term safety or large trials yet

!  Study in 2016 with Avg 4.2 yr F/u, no long term adverse effects

!  Consider carefully, only in pts with nl renal fxn

!  Still need HRCT!

Vanhee A, et al. Neurology 86;16 Supplement P4.113, April 2016

MR – Cg with IT Gad !  Technique:

!  Mult osseous defects, no/intermittent leaks, postop !  HRCT first !  Off-label use consent !  Pre-gad MR Cg sequences with T1 and T2w images !  LP – 0.5 ml intrathecal gadopentetate dimegulmine in

4 cc sterile, pres free saline, or CSF !  Scan at 1 hour, then again at 4-24 hours, as needed

!  Fat sat T1w post in multiple planes

45 yo F w h/o int leak, mult potential osseous defects bilat

Cor T2W MR Cg Cor T1W FS MR Cg w IT Gad

Summary: Algorithm for Work-up of CSF leak

B2-transferrin

Positive HRCT

Multiple osseous defects

CT Cisternogram

Single osseous defect

No further imaging; most

likely site of CSF leak

Suspect Meningo-

encephalocele MR

Cisternogram

Negative

No imaging;

unlikely to be CSF

leak

Unable to collect fluid HRCT

MR Cisternogram, consider Intrathecal

contrast if high suspicion

Summary: SB Trauma

!  Complex !  Even linear nondisplaced fractures can be

assoc with complications !  CTA/CTV:

!  Carotid canal !  Cavernous sinus !  Jugular foramen/sigmoid sinus !  Clivus !  Occipital condyle

Skull base fractures: Checklist

" Posterior table frontal sinus " Anterior skull base " Skull base foramina (ON, SOF,

FR, FO, IAC, hypoglossal canal) " Carotid canal " Sigmoid sinus/jugular foramen " Clivus " Occipital condyle

References !  Baugnon KL, Hudgins PA. Skull base fractures and their complications. NI Clin N

Am 2014; 24(3):439-465.

!  Manson PN, Stanwix MG, Yaremchuk MJ, et al. Frontobasal fractures: anatomical

classification and clinical significance. Plast Reconstr Surg 2009;124:2096-2106.

!  Guy WM, Brissett AE. Contemporary management of traumatic fracture of the

frontal sinus. Otolaryngol Clin North Am 2013;46:733-748.

!  Gean AD, Fischbein NJ, Purcell DD, et al. Benign anterior temporal epidural

hematoma: indolent lesion with a characteristic CT imaging appearance after blunt

trauma. Radiology 2010;257(1):212-8..

!  York G, et al. Assoication of internal carotid artery injury with carotid canal

fractures in patients with head trauma. Am J Roentgenol 2005;184(5):1672-8.

References !  Miller PR, et al. Blunt cerebrovascular injuries: diagnosis and treatment. J Trauma

2001;51:279-85.

!  Ochalski PG, et al. Fractures of the clivus: a contemporary series in the computed

tomography era. Neurosurgery 2009;65(6):1063-9.

!  Kwong Y, et al. Fracture mimics on temporal bone CT: a guide for the radiologist.

AJR Aug 2012; 199(2):428-34

!  Delgado AJE, et al. Prevalence of traumatic dural venous sinus thrombosis in

high-risk acute blunt head trauma patients evaluated with multidetector CT.

Radiology 2010 May;255(2):570-7.

References

•  Bleier BS, et al. Preliminary study on the stability of beta-2 Transferrin in extracorporeal CSF. Otolaryngol Head Neck Surg 2011;144:101-3.

•  Stone JA, et al. Evaluation of CSF Leaks: High-resolution CT compared with

contrast-enhanced CT and radionuclide cisternography. AJNR 1999;20:706-712 •  Shetty PG et al. Evaluation of high-resolution CT and MR cisternography in the

diagnosis of cerebrospinal fluid fistula. Am J Neuroradiol 1998;19:633-639. •  El Gammal T, et al. Cerebrospinal fluid fistula: detection with MR cisternography.

Am J Neuroradiol 1998;19:627-631. !  Lloyd MN, et al. Post-traumatic CSF rhinorrhoea: modern HRCT is all that is

required for the effective demonstration of the site of leakage. Clin Radiol 1994;49:100-103.

!  Stone JA, et al. Evaluation of CSF Leaks: High-resolution CT compared with

contrast-enhanced CT and radionuclide cisternography. AJNR 1999;20:706-712

References, cont !  Lloyd KM, Delgaudio JH, Hudgins PA Imaging of Skull Base Cerebrospinal Fluid

Leaks in Adults. Radiology 2008;248:725-36. !  Dillon WP. Intrathecal Gadolinium: Its Time has Come? AJNR 2008;29:3-4. !  Manes, RP, Ryan MVV, Marple BF. A novel finding on CT in the diagnosis and

localization of CSF leaks without a clear bony defect. Int Forum Allergy Rhinol 2012;2(5):402-404.

!  Sampaio MH, et al. Predictability of quantification of beta-trace protein for diagnosis of cerebrospinal fluid leak: cutoff determination in nasal fluids with two control groups. Am J Rhinol Allergy 2009;23(6):585-90.

!  Selcuk H, et al. Intrathecal Gadolinium-Enhanced MR Cisternography in the Evaluation of CSF leakage. AJNR 2010;31:71-75.

!  Algin O, et al. The contribution of 3D-CISS and contrast enhanced MR cisternography in detecting cerebrospinal fluid leak in patients with rhinorrhea. British Journal of Radiology 2010;83:225-232.

!  LaFata V, et al. CSF leaks: Correlation of High-Resolution CT and Multiplanar reformations with Intraoperative Endoscopic findings. AJNR 2008;29:536-41.

!  Vanopdenbosch LJ, et al. MRI with intrathecal Gadolinium to Detect a CSF leak: a prospective open-label cohort study. J Neurol Neursurg Psychiatry 2011;82:456-458.

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Skull Base Trauma Disclosures - Educational Symposia€¦ · Skull base trauma ! Up to 16% of CHI ! High velocity impact ! Penetrating trauma