An 18-year-old woman referred to the Emergency Department of the Hospital Universitario 12 de Octubre from another hospital centre after suffering a traffic accident with direct craniofacial impact. The patient reported no personal history of interest and on admission had a Glasgow Coma Scale (GCS) of 15. Physical examination revealed significant oedema and bilateral periorbital haematoma with crepitus, right otorrhagia and rhinorrhoea from the left nostril. When assessed by the ophthalmology department, no decrease in visual acuity, diplopia or alterations in extrinsic ocular movements were observed, although left macular oedema was observed. There were no initial alterations of cranial nerves except for paraesthesia in the V1 territory. Palpation revealed significant decalation in the left supraorbital rim.
With the diagnosis of suspected skull base fracture with associated cerebrospinal fluid fistula, a craniofacial CAT scan was requested, showing a comminuted left frontobasal fracture-split with associated involvement of the ipsilateral temporal scale and pneumocephalus. Fracture of the right cranialmost portion of the cranial aspect of the right cerebellum lateral to the superior semicircular ducts. Fracture without displacement of the anterior wall of the right carotid canal. At the level of the brain there were multiple contusive haemorrhagic foci mainly located in both frontal lobes, parieto-temporal endocranial bone fragments and minimal subarachnoid haemorrhage in the tentorium with right occipital epidural haematoma, probably due to contrecoup injury.
After diagnostic confirmation of cerebrospinal fluid fistula (beta-2 transferrin test +) associated with complex frontobasal fracture, it was decided, together with the Neurosurgery Department, to carry out surgical treatment:
Left bicoronal and subcranial approach with excision of impacted frontobasal fragments. Repair of basal dural tears by means of duraplasty and fibrin adhesive after aspiration of the contused left frontal base. Obliteration of the frontal sinus after obturation of the duct with calotte bone chip and DBX (demineralised bone matrix) and curettage of the sinus mucosa. Reconstruction of the left orbital roof with titanium mesh and bone fragments fixed to it. Reduction and osteosynthesis of frontotemporal fractures and left supraorbital rim. Temporal muscle pectomy.
The patient was assessed at regular post-surgical check-ups without presenting any symptoms. Control imaging tests showed postoperative changes and complete frontal sinus obliteration.
Eighteen months after the operation, the patient started again with occasional unilateral rhinorrhoea from the right nostril. After ordering imaging tests (high-resolution CT and MRI), a post-traumatic sphenoidal meningocele was observed with a paramedial cranial base defect measuring 1.5cm by 1.5cm. It was associated with a cystic cavity of right frontobasal cerebrospinal fluid.
Given the characteristics of the lesion, transnasal endoscopic treatment was decided. Opening of the anterior wall of the sphenoid sinus with visualisation of the herniated meningocele. Intracranial dissection and monopolar coagulation until progressive intracranial reduction. The defect is delimited at the cranial base and fibrin adhesive is applied. The sphenoid sinus was obliterated with abdominal fat. Lumbar drainage was maintained until the 5th postoperative day and the anterior nasal packing was removed the same day without evidence of intranasal fluid leakage.
Postoperatively, control MRI scans were performed, showing the absence of a previous meningocele and adequate obliteration of the cranial defect with autogenous fat. The patient is currently in the third postoperative year after the last operation without recurrence of meningocele or clinical signs of cerebrospinal fluid fistula.
