Severe craniofacial fractures with frontobasal involvement and cerebrospinal fluid fistula: Indications for surgical repair

Background: The management of posttraumatic cerebrospinal fluid (CSF) fistulae is a controversial topic. Although recent literature shows that endoscopic repair of CSF fistula is efficacious and minimally invasive, in specific conditions open operative approach remains imperative. Methods: A series of 36 patients underwent surgery for posttraumatic CSF fistula according to specific selection criteria. These criteria included: bone displacement more than 1 cm (5 cases), location of fracture in proximity to the midline (6 cases), involvement of cribriform plate (12 cases), presence of encephalocele (3 cases), and failure of the conservative treatment (10 cases). The dural defect was closed using vascularized pericranium and fibrin glue. Closure of the basal bone defect was necessary in very large fractures or in special localization of the fistula, such as near the optic nerve. Mean clinical follow-up was 5.7 years. Results: Two patients presented meningitis without sequelae, and 12 with hyposmia. One patient died of the severity of the primary brain injury and associated extracranial lesions. None of the patients had recurrence. Conclusions: Our results indicate that surgical dural repair in selected cases is related to low morbidity and mortality preserving from delayed risks such as recurrence and infections.