title: Basal skull fractures are associated with mortality in pediatric severe traumatic brain injury.
abstract: BACKGROUND
  Basal skull fractures (BSFs) are caused by blunt force trauma, occurring in the temporal, occipital, sphenoid, and/or ethmoid bones. In pediatric severe traumatic brain injury (sTBI), there is a paucity of data on BSFs. Our goal was to investigate the BSF prevalence, anatomy, and association with short-term outcomes in pediatric sTBI.
  
  
  METHODS
  We retrospectively reviewed all severely injured (Injury Severity Score ≥12) pediatric patients (aged <18 years) admitted to our hospital after experiencing an sTBI (Glasgow Coma Scale score ≤8 and head Abbreviated Injury Scale score ≥4). Neuroimaging for all sTBI patients was reviewed for skull fractures. Data were analyzed with both univariate and multivariate techniques.
  
  
  RESULTS
  Of the 180 patients with sTBI, 47 had BSFs for a prevalence of 26% (69 BSFs in total; 16 sTBI patients had ≥2 BSFs). The squamous temporal bone was fractured most frequently (n=30/47 sTBI patients with BSFs). Patients with BSFs were heavier and had more facial injuries than those without (p < 0.05) but were similar in all other admission demographics, injury profiles, and clinical characteristics. Cerebrospinal fluid leak was found in 32% (n = 15 of 47) of BSF patients (otorrhea, n = 12; rhinorrhea, n = 1; otorrhea/rhinorrhea, n = 2; p < 0.001). Mortality, acute central diabetes insipidus, and fewer ventilator-free days were associated with BSFs (p < 0.005), whereas in sTBI survivors, BSFs were associated with longer lengths of stay (p < 0.05). Multiple logistic regression showed that BSFs were positively associated with the presence of subarachnoid hemorrhage (odds ratio [OR], 4.00; p = 0.001), contusion (OR, 2.48; p = 0.029), herniation (OR, 3.40; p = 0.037), and cerebral edema (OR, 2.30; p = 0.047) but negatively associated with diffuse axonal injury (OR, 0.20; p = 0.003). BSFs and mortality were strongly associated (OR, 6.87; p = 0.019).
  
  
  CONCLUSIONS
  BSFs occurred in 26% of pediatric sTBI patients. The temporal bone was fractured in two thirds of sTBI patients with BSFs, and one third was associated with cerebrospinal fluid leaks. BSFs represent a significant linear blunt force and are independent predictors of mortality.
  
  
  METHODS
  Prognostic and epidemiologic study, level III.
authors.forename: Ibrahim
authors.initials: I
authors.lastname: Alhelali
authors.forename: Tanya Charyk
authors.initials: TC
authors.lastname: Stewart
authors.forename: Jennifer
authors.initials: J
authors.lastname: Foster
authors.forename: Ibrahim M
authors.initials: IM
authors.lastname: Alharfi
authors.forename: Adrianna
authors.initials: A
authors.lastname: Ranger
authors.forename: Hani
authors.initials: H
authors.lastname: Daoud
authors.forename: Douglas D
authors.initials: DD
authors.lastname: Fraser
mesh_terms: D000293:Adolescent; D001930:Brain Injuries / Q000150:complications* / Q000401:mortality* / Q000473:pathology; D002648:Child; D002675:Child, Preschool; D003422:Critical Care; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D009864:Ontario; D063868:Patient Outcome Assessment; D015995:Prevalence; D012189:Retrospective Studies; D012307:Risk Factors; D012887:Skull Fractures / Q000453:epidemiology* / Q000473:pathology*; D015599:Trauma Severity Indices; D055815:Young Adult