title: Extensive traumatic anterior skull base fractures with cerebrospinal fluid leak: classification and repair techniques using combined vascularized tissue flaps.
abstract: OBJECTIVE
  This article introduces a classification scheme for extensive traumatic anterior skull base fracture to help stratify surgical treatment options. The authors describe their multilayer repair technique for cerebrospinal fluid (CSF) leak resulting from extensive anterior skull base fracture using a combination of laterally pediculated temporalis fascial-pericranial, nasoseptal-pericranial, and anterior pericranial flaps.
  
  
  METHODS
  Retrospective chart review identified patients treated surgically between January 2004 and May 2014 for anterior skull base fractures with CSF fistulas. All patients were treated with bifrontal craniotomy and received pedicled tissue flaps. Cases were classified according to the extent of fracture: Class I (frontal bone/sinus involvement only); Class II (extent of involvement to ethmoid cribriform plate); and Class III (extent of involvement to sphenoid bone/sinus). Surgical repair techniques were tailored to the types of fractures. Patients were assessed for CSF leak at follow-up. The Fisher exact test was applied to investigate whether the repair techniques were associated with persistent postoperative CSF leak.
  
  
  RESULTS
  Forty-three patients were identified in this series. Thirty-seven (86%) were male. The patients' mean age was 33 years (range 11-79 years). The mean overall length of follow-up was 14 months (range 5-45 months). Six fractures were classified as Class I, 8 as Class II, and 29 as Class III. The anterior pericranial flap alone was used in 33 patients (77%). Multiple flaps were used in 10 patients (3 salvage) (28%)--1 with Class II and 9 with Class III fractures. Five (17%) of the 30 patients with Class II or III fractures who received only a single anterior pericranial flap had persistent CSF leak (p < 0.31). No CSF leak was found in patients who received multiple flaps. Although postoperative CSF leak occurred only in high-grade fractures with single anterior flap repair, this finding was not significant.
  
  
  CONCLUSIONS
  Extensive anterior skull base fractures often require aggressive treatment to provide the greatest long-term functional and cosmetic benefits. Several vascularized tissue flaps can be used, either alone or in combination. Vascularized flaps are an ideal substrate for cranial base repair. Dual and triple flap techniques that combine the use of various anterior, lateral, and nasoseptal flaps allow for a comprehensive arsenal in multilayered skull base repair and salvage therapy for extensive and severe fractures.
authors.affiliation: Departments of 1 Neurosurgery.
authors.forename: Jacob B
authors.initials: JB
authors.lastname: Archer
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
authors.forename: Hai
authors.initials: H
authors.lastname: Sun
authors.affiliation: Departments of 1 Neurosurgery.
authors.forename: Phillip A
authors.initials: PA
authors.lastname: Bonney
authors.affiliation: Oral and Maxillofacial Surgery.
authors.forename: Yan Daniel
authors.initials: YD
authors.lastname: Zhao
authors.affiliation: Otorhinolaryngology, and.|Biostatistics and Epidemiology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma; and.
authors.forename: Jared C
authors.initials: JC
authors.lastname: Hiebert
authors.affiliation: Otorhinolaryngology, and.
authors.forename: Jose A
authors.initials: JA
authors.lastname: Sanclement
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
authors.forename: Andrew S
authors.initials: AS
authors.lastname: Little
authors.affiliation: Departments of 1 Neurosurgery.
authors.forename: Michael E
authors.initials: ME
authors.lastname: Sughrue
authors.affiliation: Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Theodore
authors.affiliation: Oral and Maxillofacial Surgery.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: James
authors.affiliation: Departments of 1 Neurosurgery.|Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
authors.forename: Sam
authors.initials: S
authors.lastname: Safavi-Abbasi
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D065634:Cerebrospinal Fluid Leak / Q000209:etiology / Q000601:surgery*; D002648:Child; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D019651:Plastic Surgery Procedures; D012189:Retrospective Studies; D019291:Skull Base / Q000293:injuries*; D012887:Skull Fractures / Q000150:complications / Q000601:surgery*; D013524:Surgical Flaps; D016896:Treatment Outcome; D055815:Young Adult
keywords: anterior skull base repair; cerebrospinal fluid leak; frontal sinus; nasoseptal flap pericranial flap; temporoparietal fascial flap; traumatic meningitis