The bifrontal craniotomy in the management of posttraumatic CSF fistula: A long term follow-up of 44 patients

Between 1987 and 1995 a series of 44 patients (30 men and 14 women) underwent bifrontal craniotomy and anterior fossa exploration for repair of posttraumatic cerebrospinal fistula after severe head injury. There were 30 men and 14 women, with a mean age of 32 years (18 to 68). In 20 cases the clinical picture was that of a meningitis (14 streptococcus neumoniae, 3 hemophilus influenzae and 3 without germ identification). Fourteen patients had a single episode of meningitis and 6 more than one. The interval between head injury and meningitis varied from 3 days to 21 years. Rhinorrhea was present in 24 cases. It was unilateral in 11, bilateral in 3 and alternate in 3. Anosmia was a common preoperative finding and present in 37 patients. All patients had axial and coronal CT, and CT-metrizamide was done in 10. By radiology a single fracture line was identified in 16 cases and more than one in 28. Bilateral anterior fossa fractures were present in 25 patients. All patients were operated not right on but after the acute stage of trauma or meningitis. Eight patients had previous surgery (6 transcranial with acrylic repair and 2 transsphenoidal sealings). The surgical technique included a complete exploration of the anterior fossa through a bifrontal craniotomy, cranialization of the frontal sinuses, filling of the fracture line or defects with bonechips and covering the whole floor with a pediculated galeal flap. There was no surgical mortality and complications included 1 seizures and 2 anosmias. At the follow-up (1 to 9 years) there have been no recurrences. In conclusion, this technique is a reliable method for the treatment of traumatic CSF fistulas, with minimal morbidity and long lasting results.