An 18-year-old woman was referred to the Emergency Department of the 12 de Octubre University Hospital from another hospital after suffering a traffic accident with a direct craniofacial impact.
The patient had no personal history of interest and at admission had a Glasgow Coma Scale (GCS) of 15.
Physical examination revealed significant bilateral periorbital edema and hematoma with crepitation, right otorrhea and rhinorrhea due to left nasal fossa.
Assessed by the Ophthalmology Service, there was no evidence of decreased visual acuity, diplopia or alterations in extrinsic eye movements, although there was left macular edema.
There were no initial changes in cranial nerves except paresthesias in V1 territory.
Fixation was observed in the left supraorbital border.
With the diagnosis of skull base fracture with associated cerebrospinal fluid fistula, a craniofacial TAC was requested, which showed ipsilateral frontal-occipital fracture and conminuted pneumonitis associated with a head injury.
Fracture of the right petrous bone in its most craneous portion lateral to the semitendinosus canals.
Fracture without displacement of the anterior wall of the right carotid canal.
At the level of the encephalon there were multiple contusive hemorrhagic foci mainly located in both frontal lobes, parieto-temporal endocraneal bone fragments and probably minimal epidural hemorrhage in tentorium with epidural hematoma.
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After the diagnostic confirmation of cerebrospinal fluid fistula (beta-2 transferrin + test) associated with complex frontal fracture, it was decided together with the Neurosurgery Department surgical treatment performing:
Left bicoronal and subcraneal approach with excision of impacted frontal fragments.
Repair of basal durable tears by duraplasty and fibrin adhesive after left frontal base aspirate with tapered dressing.
Obliteration of the frontal sinus after obturation of the duct with a calcified bone plate DBX (demineralized bone matrix) and curettage of the sinus mucosa.
Left orbital roof fixation with titanium mesh and fixed to it.
Reduction and osteosynthesis of frontotemporal fractures and left supraorbital rim.
Temporal muscle hypoxia.
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The patient is evaluated in postoperative periodic reviews without symptoms.
Control imaging tests showed postsurgical changes and complete frontal sinus obliteration.
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Eighteen months after the intervention, the patient started again with occasional unilateral rhinorrhea due to right nasal fossa.
After requesting imaging tests (high resolution CT and MRI), a posttraumatic meningocele was observed, with a paramedian cranial base defect of 1.5cm per 1.5cm.
A cystic cavity of the right frontal fluid.
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Given the characteristics of the lesion, transnasal endoscopic treatment was decided.
Opening of the anterior sinus wall provides visualization of the herniated meningocele.
Intracranial dissection and monopolar coagulation until its progressive intracranial reduction.
The defect is delimited in the cranial base and fibrin adhesive is applied.
The sinus is obliterated with abdominal fat.
Lumbar drainage was maintained until postoperative day 5 and anterior nasal packing was removed the same day without evidence of intranasal fluid leakage.
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Follow-up nuclear magnetic resonances were performed postoperatively, showing absence of previous meningocele and adequate obliteration of a cranial defect with autogenous fat.
Currently, the patient is in the third postoperative year after the last intervention without recurrence of meningocele or clinical cerebrospinal fluid fistula.
