key: cord-0769163-s9a7ngrk
authors: Yoneoka, Yuichiro; Aizawa, Naotaka; Nonomura, Yoriko; Ogi, Manabu; Seki, Yasuhiro; Akiyama, Katsuhiko
title: Traumatic non-missile penetrating transnasal anterior skull-base fracture and brain injury with cerebrospinal fluid leak: intraoperative leak detection and an effective reconstruction procedure for a localized skull base defect especially after COVID-19 outbreak
date: 2020-06-01
journal: World Neurosurg
DOI: 10.1016/j.wneu.2020.05.236
sha: d75d64d75e97f9f645380e89298473f7f09a54c0
doc_id: 769163
cord_uid: s9a7ngrk

Abstract BACKGROUND Cerebrospinal fluid leakage in penetrating skull base injury is relatively rare compared to close head injury involving skull base fracture. CASE DESCRIPTION We report a case of a 65-year-old beekeeping man who presented with epistaxis and serous rhinorrhea. When he fell down on the ground near his bee boxes, a garden pole poked into his right nostril. He instantly removed the pole from his nostril by himself. Immediately after the removal of the pole, he developed some nasal bleeding and serous rhinorrhea. He then drove to our emergency room. Computed tomography showed pneumocephalus with minor cerebral contusion in the left frontal lobe, and penetrating injury in the left anterior skull base. His cerebrospinal fluid (CSF) leakage did not resolve spontaneously within one week after the injury under a strict bed rest. We repaired the CSF leakage using a fat (adipose tissue)-on-fascia autograft plug and caulked the defect in the anterior skull base with the fat-on-fascia graft (FFG) plug through the left nostril under endoscopic vision. The CSF rhinorrhea was successfully controlled. Intranasal local application of fluorescein aided in the detection of the flow direction of CSF leakage. CONCLUSIONS Endonasal endoscopic caulking of a skull base defect using FFG plug is useful for CSF leakage due to localized skull base defect, in particular for the post-COVID-19 era, because it is simple, low-cost, and timesaving: requiring no special skills or no sophisticated instruments, thus reducing infection risks during the surgery. (239 words)

Intracranial penetrating injury through the nose is uncommon [1]. Among these types of injuries, transnasal penetration by a non-missile foreign body is rare [2] . Cerebrospinal fluid (CSF) leak in penetrating skull injury is also relatively rare compared to close head injury involving skull base fracture [3] . Transnasal penetrating brain injuries, albeit rare, are a medical emergency, and they need to be treated promptly [4] , whether with CSF leak or not.

In this report, we present a case of traumatic non-missile penetrating transnasal anterior skull-base fracture and brain injury with CSF leak. We demonstrate a simple method of intraoperative CSF leak detection and an effective reconstruction procedure for a localized skull base defect using fat-on-fascia graft (FFG). Both methods are available without any special instrument so as to improve reconstruction operations in efficiency. In particular, we introduce a practical closure FFG plug for localized skull base defect based on our experience [5, 6, 7, 8, 9] , especially for the post-COVID-19 era, because it is simple, low-cost, and timesaving: requiring no special skills or no sophisticated instruments that cause aerosol, thus reducing infection risks during the surgery.

A 65-year-old beekeeping man presented to the emergency department with a 30-minute history of epistaxis and serous rhinorrhea. He fell down on the ground near his bee boxes. At that time, a garden pole poked into his right nostril, and he instantly removed the pole from his nostril by himself. Immediately after the removal of the pole, he developed some nasal bleeding and serous rhinorrhea. He drove to our emergency room (ER) by himself because the 3 3 nasal bleeding and serous rhinorrhea continued. The patient's past medical history was unremarkable. He had been in his usual state of good health until this injury before admission.

In the emergency department of this hospital, the patient reported no vision changes, diplopia, dysarthria, numbness, tingling, weakness, cough, dyspnea, abdominal pain, vomiting, diarrhea, or dysuria. There was no fatigue, pharyngitis, joints stiffness, joint swelling, or myalgia. Upon examination in the ER, the patient was alert, cooperative, and oriented. His vital signs were normal. His weight was 68.4kg, his height 170.2 cm, and his body-mass index (his weight in kilograms divided by the square of his height in meters) 23.6. His nasal bleeding and serous rhinorrhea appeared intermittently on exertion. Computed tomography showed pneumocephalus with minor cerebral contusion in the left frontal lobe, and penetrating injury in the left anterior skull base ( Figure 1 , A-E). Symptoms of infection, such as pyrexia, nuchal stiffness, purulent rhinorrhea, or purulent otorrhea were not observed. As a first step in the treatment for the skull base injury with CSF leak, the patient wanted to be treated conservatively [10] , so he was ordered to take a complete bed rest, and piperacillin (2g x 3/day) was administrated prophylactically. He declined placement of a lumber subarachnoid CSF drainage at the start of the conservative treatment. His CSF leakage did not resolve spontaneously within one week after the injury under strict bed rest. During his experience of this conservative rest therapy, the patient selected an endonasal and endoscopic repair as a less-invasive procedure. We presumed that the pole was inserted into the right nostril, crossed the nasal septum obliquely, and penetrated the left cribriform plate into the right frontal lobe The patient did not suffer any relapse of CSF leak at 16 months after the reconstruction using the FFG plug. He has completely returned to his responsibilities of beekeeping.

Transnasal intracranial penetrating injury is rare [11] . Transnasal and transorbital penetrating foreign body injuries are a relatively uncommon occurrence, but when they do occur, they require rapid workup and interdisciplinary management to prevent acute and delayed complications [12] . We used a fat-on-fascia graft (FFG) plug for repair of a localized anterior skull base defect caused by a traumatic non-missile penetrating injury and managed it well with long term stability. In light of our past experience [5, 6, 7, 8, 9] , FFG plugs are effective, inexpensive, safe, and usable for any surgeons without requiring special skills.

In 2020, the novel coronavirus, SARS-CoV-2, and its infection, COVID-19, has quickly become a worldwide threat to health, travel, and commerce [13] . International experience with COVID-19 suggests it poses a significant risk of infectious transmission to skull base surgeons, due to high nasal viral titers and the unknown potential for aerosol generation The key to successful management of CSF leak is to precisely identify the site of the dural tear [21, 22] . To help better localize the site and extent of the leaks, some authors advocate the use of intraoperative fluorescein [23, 24] . In our case, we applied intraoperative fluorescein near the site of the dural tear/defect and identified the CSF current or flow on the mucosa in the nasal cavity. Local application of fluorescein helped better localize the site and the extent of CSF leaks, even if it was not administered intrathecally (Figure 3 , B-C). 6 6

Endonasal endoscopic caulking of a skull base defect using an FFG plug is useful for dealing with CSF leakage due to localized skull base defect, especially after the COVID-19 outbreak because of its simplicity and unnecessity of special skills and sophisticated instruments. 

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