Download PDF
J Neurol Surg A Cent Eur Neurosurg 2024; 85(02): 147-154
DOI: 10.1055/a-1994-9330
Original Article

Variations in the Neurosurgical Management of Depressed Skull Fractures in Adults: An International Cross-Sectional Survey

Amir Suliman
1   Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
,
Nithish Jayakumar 
1   Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
,
Bipin Chaurasia 
2   Department of Neurosurgery, Gandak Hospital, Birgunj, Nepal
,
Damian Holliman
1   Department of Neurosurgery, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
› Author Affiliations Funding None.
› Further Information
Also available at
    Permissions and Reprints

Abstract

Background Depressed skull fractures have been well described since antiquity, yet its management remains controversial. Contentious issues include the use of prophylactic antibiotics and antiepileptics, the role of nonoperative management, and the replacement/removal of bone fragments. Our objective was to explore the management patterns of closed and open depressed skull fractures across the world.

Methods A 23-item, web-based survey was distributed electronically to the members of national neurosurgical associations, and on social media platforms. The survey was open for data collection from December 2020 to April 2021.

Results A total of 218 respondents completed the survey, representing 56 countries.With regard to open fractures, most respondents (85.8%) treated less than 50 cases annually. Most respondents (79.4%) offered prophylactic antibiotics to all patients with open fractures, with significant geographical variation (p < 0.001). Less than half of the respondents (48.2%) offered prophylactic antiepileptics. Almost all respondents (>90%) reported the following indications as important for surgical management: (1) grossly contaminated wound, (2) dural penetration, (3) depth of depression, and (4) underlying contusion/hematoma with mass effect. Most respondents treated less than 50 cases of closed depressed skull fractures annually. Most European respondents (81.7%) did not offer prophylactic antiepileptics in comparison to most Asian respondents (52.7%; p < 0.001). Depth of depression, an underlying hematoma/contusion with mass effect, and dural penetration were the most important surgical indications.

Conclusions There remains a great degree of uncertainty in the management strategies employed across the world in treating depressed fractures, and future work should involve multinational randomized trials.

Keywords

depressed skull fractures - compound depressed skull fractures - traumatic brain injury - online survey - cross-sectional study


Publication History

Received: 08 March 2022

Accepted: 05 December 2022

Accepted Manuscript online:
08 December 2022

Article published online:
01 May 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Ganz JC, Arndt J. A history of depressed skull fractures from ancient times to 1800. J Hist Neurosci 2014; 23 (03) 233-251
    CrossrefPubMedSearch in Google Scholar
  • 2 Stein SC. The evolution of modern treatment for depressed skull fractures. World Neurosurg 2019; 121: 186-192
    CrossrefPubMedSearch in Google Scholar
  • 3 Bullock MR, Chesnut R, Ghajar J. et al; Surgical Management of Traumatic Brain Injury Author Group. Surgical management of depressed cranial fractures. Neurosurgery 2006;58(3, Suppl):S56–S60, discussion Si–Siv
    PubMed
  • 4 Mukherjee KK, Dhandapani S, Sarda AC. et al. Prospective comparison of simple suturing and elevation debridement in compound depressed fractures with no significant mass effect. Acta Neurochir (Wien) 2015; 157 (02) 305-309
    CrossrefPubMedSearch in Google Scholar
  • 5 Heary RF, Hunt CD, Krieger AJ, Schulder M, Vaid C. Nonsurgical treatment of compound depressed skull fractures. J Trauma 1993; 35 (03) 441-447
    CrossrefPubMedSearch in Google Scholar
  • 6 van den Heever CM, van der Merwe DJ. Management of depressed skull fractures. Selective conservative management of nonmissile injuries. J Neurosurg 1989; 71 (02) 186-190
    CrossrefPubMedSearch in Google Scholar
  • 7 Ali B, Ghosh A. Antibiotics in compound depressed skull fractures. Emerg Med J 2002; 19 (06) 552-553
    CrossrefPubMedSearch in Google Scholar
  • 8 Braakman R. Depressed skull fracture: data, treatment, and follow-up in 225 consecutive cases. J Neurol Neurosurg Psychiatry 1972; 35 (03) 395-402
    CrossrefPubMedSearch in Google Scholar
  • 9 Neville IS, Amorim RL, Paiva WS, Sanders FH, Teixeira MJ, de Andrade AF. Early surgery does not seem to be a pivotal criterion to improve prognosis in patients with frontal depressed skull fractures. BioMed Res Int 2014; 2014: 879286
    CrossrefPubMedSearch in Google Scholar
  • 10 World Federation of Neurosurgical Societies. . WFNS Member Societies. Accessed May 15, 2021 at: https://www.wfns.org/all-member-societies
    PubMed
  • 11 Mukhopadhyay S, Punchak M, Rattani A. et al. The global neurosurgical workforce: a mixed-methods assessment of density and growth. J Neurosurg 2019; 130 (04) 1-7
    CrossrefPubMedSearch in Google Scholar
  • 12 Nadell J, Kline DG. Primary reconstruction of depressed frontal skull fractures including those involving the sinus, orbit, and cribriform plate. J Neurosurg 1974; 41 (02) 200-207
    CrossrefPubMedSearch in Google Scholar
  • 13 AbdelFatah MA. Management of bone fragments in nonmissile compound depressed skull fractures. Acta Neurochir (Wien) 2016; 158 (12) 2341-2345
    CrossrefPubMedSearch in Google Scholar
  • 14 Prakash A, Harsh V, Gupta U, Kumar J, Kumar A. depressed fractures of skull: an institutional series of 453 patients and brief review of literature. Asian J Neurosurg 2018; 13 (02) 222-226
    Thieme ConnectPubMedSearch in Google Scholar
  • 15 Wylen EL, Willis BK, Nanda A. Infection rate with replacement of bone fragment in compound depressed skull fractures. Surg Neurol 1999; 51 (04) 452-457
    CrossrefPubMedSearch in Google Scholar
  • 16 Akram M, Ahmed I, Qureshi NA, Bhatti SH, Ishfaq A. Outcome of primary bone fragment replacement in compound depressed skull fractures. J Coll Physicians Surg Pak 2007; 17 (12) 744-748
    PubMedSearch in Google Scholar
  • 17 Fountain DM, Henry J, Honeyman S. et al; UK Cranial Reconstruction Registry (UKCRR) Collaborative, British Neurosurgical Trainee Research Collaborative (BNTRC). First report of a multicenter prospective registry of cranioplasty in the United Kingdom and Ireland. Neurosurgery 2021; 89 (03) 518-526
    CrossrefPubMedSearch in Google Scholar
  • 18 Shokouhi G, Naseri Alavi SA, Shakeri M, Salehpour F, Meshkini A, Kosari-Nasab M. Correlation of fracture depression area and dural tear among patients with depressed skull fracture. J Surg Trauma 2020; 8 (03) 108-111
    PubMedSearch in Google Scholar
  • 19 Jennett B, Miller JD, Braakman R. Epilepsy after monmissile depressed skull fracture. J Neurosurg 1974; 41 (02) 208-216
    CrossrefPubMedSearch in Google Scholar
  • 20 Hoffman H, Otite FO, Chin LS. Venous injury in patients with blunt traumatic brain injury: retrospective analysis of a national cohort. Neurocrit Care 2022; 36 (01) 116-122
    CrossrefPubMedSearch in Google Scholar
  • 21 Aziz MM, Molla S, Abdelrahiem HA, Dawood OM. Depressed skull fractures overlying dural venous sinuses: management modalities and review of literature. Turk Neurosurg 2019; 29 (06) 856-863
    PubMedSearch in Google Scholar
  • 22 LeFeuvre D, Taylor A, Peter JC. Compound depressed skull fractures involving a venous sinus. Surg Neurol 2004; 62 (02) 121-125 , discussion 125–126
    CrossrefPubMedSearch in Google Scholar
  • 23 Taghyan M, Moussa A, Nouby R. Compound depressed skull fractures overlying dural venous sinuses. Pan Arab J Neurosurg 2008; 12 (02) 51-55
    PubMedSearch in Google Scholar
  • 24 Elshanawany A, Ragab M. Delayed neurological deterioration after depressed fracture over superior sagittal sinus: our experience with 13 patients. J Neurol Surg A Cent Eur Neurosurg 2020; 81 (04) 324-329
    Thieme ConnectPubMedSearch in Google Scholar
  • 25 Zabalo San Juan G, Vázquez Míguez A, Zazpe Cenoz I. et al. Intracranial hypertension caused by superior sagittal sinus stenosis secondary to a depressed skull fracture: case report and review of the literature. Neurocirugia (Astur : Engl Ed) 2019; 30 (05) 243-249
    CrossrefPubMedSearch in Google Scholar
  • 26 Rivkin MA, Saraiya PV, Woodrow SI. Sinovenous thrombosis associated with skull fracture in the setting of blunt head trauma. Acta Neurochir (Wien) 2014; 156 (05) 999-1007 , discussion 1007
    CrossrefPubMedSearch in Google Scholar
  • 27 Dewan MC, Rattani A, Gupta S. et al. Estimating the global incidence of traumatic brain injury. J Neurosurg 2018; 130 (04) 1-18
    PubMedSearch in Google Scholar
  • 28 James SL, Theadom A, Ellenbogen RG. et al; GBD 2016 Traumatic Brain Injury and Spinal Cord Injury Collaborators. Global, regional, and national burden of traumatic brain injury and spinal cord injury, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol 2019; 18 (01) 56-87
    CrossrefPubMedSearch in Google Scholar
  • 29 Hyder AA, Wunderlich CA, Puvanachandra P, Gururaj G, Kobusingye OC. The impact of traumatic brain injuries: a global perspective. NeuroRehabilitation 2007; 22 (05) 341-353
    CrossrefPubMedSearch in Google Scholar
  • 30 Oberjé EJM, Tanke MAC, Jeurissen PPT. Antimicrobial stewardship initiatives throughout Europe: proven value for money. Infect Dis Rep 2017; 9 (01) 6800
    CrossrefPubMedSearch in Google Scholar
  • 31 Malomo TA, Oyemolade TA, Adeleye AO. Determinants of timing of presentation of neurotrauma patients to a neurosurgical center in a developing country. J Neurosci Rural Pract 2018; 9 (04) 545-550
    Thieme ConnectPubMedSearch in Google Scholar
  • 32 Ngugi AK, Bottomley C, Kleinschmidt I, Sander JW, Newton CR. Estimation of the burden of active and life-time epilepsy: a meta-analytic approach. Epilepsia 2010; 51 (05) 883-890
    CrossrefPubMedSearch in Google Scholar
  • 33 Amudhan S, Gururaj G, Satishchandra P. Epilepsy in India I: epidemiology and public health. Ann Indian Acad Neurol 2015; 18 (03) 263-277
    CrossrefPubMedSearch in Google Scholar
  • 34 Vaca SD, Kuo BJ, Nickenig Vissoci JR. et al. Temporal delays along the neurosurgical care continuum for traumatic brain injury patients at a tertiary care hospital in Kampala, Uganda. Neurosurgery 2019; 84 (01) 95-103
    CrossrefPubMedSearch in Google Scholar
  • 35 Raykar NP, Yorlets RR, Liu C. et al. A qualitative study exploring contextual challenges to surgical care provision in 21 LMICs. Lancet 2015; 385 (Suppl. 02) S15
    CrossrefPubMedSearch in Google Scholar