Basilar Skull Fracture and Concern Over CSF Leak

[Mr. J.]

Hi,

Fourteen days ago I suffered a sports-related closed-head injury. I apparently hit 2 parts of my head. The orbit around my right eye was broken in 2 places and I had a racoon eye. Then, on the left side of my head I got a basilar skull fracture (temporal area), 2 small brain hemmorhages, and a small pneumocephallus. All fractures non-displaced. In the ER, a CT-scan was done which showed these injuries. The next day another CT-scan showed fluid had developed in my left mastoid and my left middle-ear. THE INJURY HAPPENED 14 DAYS AGO BUT THE LEFT EAR PRESSURE/PAIN/DISCOMFORT CONTINUES. It is worse when I get up in the morning. I am very concerned about a CSF leak but do not have any dripping.  (I was clearing blood in my morning phlem for first 10 days but that has now quit). My questions:

1) In the hospital, the neurologist thought the fluid seen on CT-scan was CSF. A different neurosurgeon last week said without dripping it probably was not CSF and he was not concerned. Does this sound likely that it is not CSF? From my research, a basilar skull fracture, pneumocephallus, and fluid in the mastoid and middle ear all point towards CSF! Can there be another explanation for this fluid?

2) I'm concerned about CSF leak into my ear. Are my concerns justified? What should I do at this point to address this concern? What tests are needed?

3) Is the neumocephallus something that should be addressed with further scans or treatment? It was described as "small" and "tiny" and "minimal" on my scans.

4) What are my meningitis chances? How can I protect myself?

Thanks.

[Mr. J.]

Thanks very much for your response.  I appreciate your help and will ask my physician about the tests you mentioned.

[CCF-Neuro-M.D.-SH]

First of all, keep in mind that I am unable to diagnose you because I am unable to examine you, this forum is for educational purposes.
   It is very likely that the fluid filling the mastoid air cells in the area of the skull fracture is CSF. That being said, it may not be a problem, unless there is a persistent leak.  If the leak only happened during the trauma, then that CSF and air (pneumocephalus-air in the head) will be re-adsorbed without any consequence.  However-if you have a perisistent leak of CSF then this increases the chance that you will develop headaches, hearing problems and possible meningitis.  Low pressure headaches (caused by CSF leaks) are worse with standing up, and get better with lying flat.  Stiff neck, fever, altered mental status are all signs of meningitis.  I would suggest a CT scan after the intrathecal injection of a tracer dye (CT cysternogram) or an MRI with CINE flow study to evaluate for CSF leak.  If you develop any signs of meningitis, seek help immeadiately to be started on antibiotics.
   I hope this has been helpful.

[Mr. J.]

Hello Again,

I had a follow-up CT-scan done yesterday (now nearly three weeks after accident).  It is still showing fluid in my mastoid.  I am concerned about this.  Without any noticeable external dripping, is there some way of identifying what that fluid is - to rule out CSF leak?

Thanks so much.  I really  need some help and direction on what to do.

[Mr. J.]

Please, can you respond to one more thing - it is very important.  My neurosurgeon says even if it is a small CSF leak we would probably not do anything about it anyway because the risks of surgery would outweigh the potential benefits.  And he thinks that a small CSF leak would not carry as much meningitis risk as a larger one.  Does this approach sound reasonable?