Day: July 15, 2019

How Common Are Cerebrospinal Fluid Leaks After Minor Head Trauma?

Patient Presentation
A 7-year-old male came to clinic for follow up after tripping and falling 6 days previously. He had hit his face on a table and then on the floor sustaining a contusion above his left eyebrow and having epistaxis. He denied any loss of consciousness or emesis. The epistaxis was controlled within 10 minutes and he was seen at a local emergency room, where he was found to have a small contusion, no nasal fracture or septal hematoma. He had a small blood clot on the lateral area of his nostril. Mental status, dental and neck examinations were reportedly normal. His mother said that in the evening he had a headache but had not had any others. She noted that he been doing his regular activities but was significantly more tired in the evenings and went to bed early. He reported no sleep disturbance or nausea, nor difficulties in speaking, talking or thinking. It was not taking him longer to do his work at school and he was able to play on the playground. His mother had kept him out of gym class. His mother noted that the contusion was improving and that he had expelled a small clot from his nose without additional bleeding, but had noted a small amount of rhinorrhea for a couple of days after the clot was expelled. She was concerned because she was a neurosurgical nurse and was worried about cerebrospinal fluid leaking. The rhinorrhea was not continuous and she had only noticed it a few times, with none in the past 1-2 days. The patient did not notice it. They denied any coughing or seasonal allergic rhinitis. The past medical history was notable for excessive cerumen that required intermittent debridement.

The pertinent physical exam showed a well-appearing male in no distress with normal vital signs. HEENT showed a tiny healing contusion above the left eyebrow. No other facial abnormalities were seen. His nasal examination showed no rhinorrhea, hematoma or bleeding. His pharynx was negative. His ears were blocked with cerumen. His neurological examination was negative.

The diagnosis of a healing facial contusion along with probably mild concussion was made. His mother was counseled that although the patient seemed to be doing well at school, that the excessive tiredness was probably due to mild concussion. The physician recommended additional brain rest for a couple of days over the weekend and then to monitor the patient once he resumed his normal activities. “I can understand why you would be concerned about the rhinorrhea but this is more likely due to his nose making some additional fluid to keep the area clean or that he could have had a cold. He didn’t have a nasal fracture, plus it was a low-velocity fall so it would be really unusual for this to be a facial or skull fracture causing a CSF leak,” the physician said. Two days later the boy was seen by otolaryngology for his regularly scheduled followup. They found normal nasal structures and no rhinorrhea.

Discussion
Basilar skulls fractures are relatively common occurring in 4-20% of all skull fractures. Motor vehicle accidents, significant falls from heights and blunt trauma are the most common causes of basilar skull fractures. Basilar skulls fractures are even less common in children than adults. Complications can include meningitis, cerebrospinal fluid (CSF) leaks, cranial nerve injuries or even potentially death. With more significant trauma to the head and body, it is not surprising that complications are more likely.

Nasoethmoid facial fractures have similar common mechanisms of injury including motor vehicle accident, falls, and pedestrian struck injuries.

A review of the timing for concussion symptom resolution can be found here.

Learning Point
CSF leaks can present as otorrhea or rhinorrhea with a basilar skull fracture. Most leaks occur within 48 hours of trauma and most stop without specific treatment usually within a couple of days. A study of hospitalized patients with isolated basilar skull fracture using hospital diagnosis data (N=3563 pediatric patients) found that rates were 2.3% for CSF leaks and 0.48% meningitis respectively.

In a long-term follow up study of post-traumatic basilar skull fractures in hospitalized children (N=196), 28% had CSF leak with 23% having rhinorrhea, and 89% of those stopped spontaneously. Those that didn’t had complicated presentations and courses. The authors state that for children with normal mentation, neurological examination and CT imaging findings in the emergency room after blunt head trauma, that basilar skull fractures have a low-risk of complications and patients can be discharged with outpatient followup.

For CSF leaks that do not spontaneously resolve, patients may be tried on medication that inhibits CSF production such as acetazolamide, and may have an external CSF drainage device placed. Surgical treatment is usually reserved for those with persistent leads more than 10-14 days or with complications.

In a study of 63 pediatric patients, the authors noted that nasoethmoid factures are uncommon fractures, that more simple fractures are often treated without surgical intervention and while complications can occur, they are usually in patients with more severe or multiple injuries. CSF leaking was not reported.

While it is true that any complication can occur in any patient, the patient above had a low-velocity injury, no nasal fracture or other known facial or skull fracture, or other major injury, and the rhinorrhea started several days after the event all of which are less common attributes for CSF leak. Additionally, most CSF leaks spontaneously resolve, therefore continued conservative management and observation was appropriate.

Questions for Further Discussion
1. After a concussion when can a child return to learning? A review can be found here.
2. What are indications for head computed tomography in head trauma?
3. How common are anatomical CSF leaks?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: https://medlineplus.gov/concussion.html and Head Injuries.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

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Cerebrospinal fluid leakage complicating skull base fractures: analysis of 81 cases.
Neurosurg Rev. 2006 Jan;29(1):64-71.

McCutcheon BA, Orosco RK, Chang DC, Salazar FR, Talamini MA, Maturo S, Magit A.
Outcomes of isolated basilar skull fracture: readmission, meningitis, and cerebrospinal fluid leak. Otolaryngol Head Neck Surg. 2013 Dec;149(6):931-9.

Leibu S, Rosenthal G, Shoshan Y, Benifla M.
Clinical Significance of Long-Term Follow-Up of Children with Posttraumatic Skull Base Fracture.
World Neurosurg. 2017 Jul;103:315-321.

Lopez J, Luck JD, Faateh M, Macmillan A, Yang R, Siegel G, Susarla SM, Wang H, Nam AJ, Milton J, Grant MP, Redett R, Tufaro AP, Kumar AR, Manson PN, Dorafshar AH. Pediatric Nasoorbitoethmoid Fractures: Cause, Classification, and Management.
Plast Reconstr Surg. 2019 Jan;143(1):211-222.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa