2024 年 47 巻 2 号 p. 84-88
Diffuse fracture of central skull base is a severe pathology which is hard to be treated because of not only intracranial injury but also cranial nerve injury and rhinorrhea.
Case: A 20–year–old man was transported to the emergency room after a collision with a passenger car while riding a motorcycle. His vital signs were stable and disoriented conscious level (GCS E4V4M6) with nasal hemorrhage and bilateral eyelid edema. His visual acuity was bilaterally counting fingers. There were no motor and sensory deficits in the upper and lower extremities. A CT scan of the head revealed bilateral frontal lobe contusions, traumatic subarachnoid hemorrhage, pneumoencephalous, and crushed fracture findings in the central skull base. The patient was firstly treated conservatively, because cerebrospinal fluid (CSF) leakage was not evident at first, and vital signs and level of consciousness were maintained. On the second day from the onset, the left visual acuity became light perception, and the light reflexes became blunted. Steroid pulse therapy was initiated, and an MRI indicated hyperintensity on STIR surrounding left optic nerve suggesting remarkable edema in the intra optic sheath. Since CSF leakage associated with a central crushed skull base fracture was also suspected, we decided to perform an emergent endoscopic surgery so as to decompress the optic nerve by releasing optic canal and repair the central skull base. At the moment of an opening of the anterior wall of the sphenoid sinus, a plenty of CSF flew out after removal of the blood clots. The center of the skull base was fractured in a crushed shape, and a part of the bony fragment was pressing on the left side of the optic chiasm. After removal of that, the left optic canal was opened as far as possible. The dural defect in the anterior cranial floor with CSF leakage was closed with a femoral fascia and a pedicled mucosal flap at the sphenoid sinus. Just after the surgery, left visual acuity was restored to counting fingers and rapid light reflex. Until the 31st day after the surgery, the patient had recovered to an effective visual acuity of 0.4, although incomplete bilateral hemianopia remained.
Endonasal endoscopic decompression of optic canal and repairment of skull base might be effective for diffuse fracture of the central skull base complicated with traumatic optic neuropathy and severe rhinorrhea.
