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762
EMERGENCY RADIOLOGY

CT of Skull Base Fractures:

Classification Systems, Complications,
and Management
David Dreizin, MD
Osamu Sakai, MD, PhD As advances in prehospital and early hospital care improve survival
Kathryn Champ, BS of the head-injured patient, radiologists are increasingly charged
Dheeraj Gandhi, MBBS with understanding the myriad skull base fracture management
Bizhan Aarabi, MD implications conferred by CT. Successfully parlaying knowledge
Arthur J. Nam, MD of skull base anatomy and fracture patterns into precise action-
Robert E. Morales, MD able clinical recommendations is a challenging task. The authors
David J. Eisenman, MD aim to provide a pragmatic overview of CT for skull base fractures
within the broader context of diagnostic and treatment planning
Abbreviations: CN = cranial nerve, CSF = algorithms. Laterobasal, frontobasal, and posterior basal fracture
cerebrospinal fluid, EAC = external auditory
­
canal, HRCT = high-resolution CT, MCF =
­ patterns are emphasized. CT often plays a complementary, sup-
middle cranial fossa, OAS = orbital apex syn- portive, or confirmatory role in management of skull base fractures
drome, OCV = otic capsule–violating
in conjunction with results of physical examination, laboratory test-
RadioGraphics 2021; 41:762–782 ing, and neurosensory evaluation. CT provides prognostic informa-
https://doi.org/10.1148/rg.2021200189 tion about short- and long-term risk of cerebrospinal fluid (CSF)
Content Codes: leak, encephalocele, meningitis, facial nerve paralysis, hearing and
From the Department of Diagnostic Radiol- vision loss, cholesteatoma, vascular injuries, and various cranial
ogy and Nuclear Medicine (D.D., K.C., D.G., nerve palsies and syndromes. The radiologist should leverage un-
R.E.M.), R. Adams Cowley Shock Trauma
Center (D.D., B.A., A.J.N.), Department of derstanding of specific strengths and limitations of CT to anticipate
Neurosurgery (B.A.), Division of Plastic Surgery next steps in the skull base fracture management plan. Additional
(A.J.N.), and Department of Otorhinolaryngol-
ogy–Head and Neck Surgery (D.J.E.), University
imaging is warranted to clarify ambiguity (particularly for potential
of Maryland Medical Center, 22 S Greene St, sources of CSF leak); in other cases, clinical and CT criteria alone
Baltimore, MD 21201; Department of Radiol- are sufficient to determine the need for intervention and the choice
ogy, Boston Medical Center, Boston University
School of Medicine, Boston, Mass (O.S.); and of surgical approach. The radiologist should be able to envision
Department of Diagnostic Radiology and Nu- stepping into a multidisciplinary planning discussion and engaging
clear Medicine, University of Maryland School
of Medicine, Baltimore, MD (K.C.). Presented neurotologists, neuro-ophthalmologists, neurosurgeons, neurointer-
as an education exhibit at the 2019 RSNA An- ventionalists, and facial reconstructive surgeons to help synthesize
nual Meeting. Received August 1, 2020; revision
requested December 14 and received December
an optimal management plan after reviewing the skull base CT
15; accepted December 23. For this journal- findings at hand.
based SA-CME activity, the authors O.S. and
D.G. have provided disclosures (see end of ar- Online supplemental material is available for this article.
ticle); all other authors, the editor, and the re-
viewers have disclosed no relevant relationships. ©
RSNA, 2021 • radiographics.rsna.org
Address correspondence to D.D. (e-mail:
david­dreizin@gmail.com).
©
RSNA, 2021

SA-CME LEARNING OBJECTIVES

After completing this journal-based SA-CME activity, participants will be able to:
„ List classification systems and conceptual frameworks for grouping and categorizing
temporal bone, anterior skull base, and clivus fractures.
Describe the key CT features of skull base fractures that guide clinical decision
„
making with respect to conservative versus surgical management, surgical timing, and
choice of surgical exposure.
Understand how multidisciplinary teams piece together often complementary, sup-
„
portive, or confirmatory CT findings with results of physical examination, laboratory
testing, and neurosensory evaluation to devise optimal treatment strategies.
See rsna.org/learning-center-rg.
RG  •  Volume 41  Number 3 Dreizin et al  763

(HRCT) imaging pearls for laterobasal, fronto-

TEACHING POINTS basal, posterior basal, and transsphenoid frac-
„ OCV fracture is the strongest imaging predictor of CSF leak as-
tures are presented in Tables 1–4.
sociated with laterobasal fractures. Patients have elevated risk
of meningitis throughout life, since the metabolically inactive
otic capsule heals through fibrous remodeling and does not Laterobasal Fractures
take to layered closures. Provided sensorineural hearing loss is
profound with no serviceable hearing in the affected ear, an Classification Systems
aggressive meatal overclosure surgery can permanently seal
the cranial cavity.
Traditional Mechanism-based Fracture
„ HRCT has added value in determining the surgical approach
Classification.—The temporal bone is the thick-
on the basis of fracture line location. In otic capsule–sparing
(OCS) fractures, susceptible segments of the facial nerve are
est part of the skull base and requires a force of
(a) the perigeniculate (~80%–93% of fractures) owing to trac- at least 1875 lb (850 kg) to fracture (12). Com-
tion at the greater petrosal nerve takeoff and (b) the mastoid plications depend on involvement of the tegmen
(20%–25% of fractures). and neurovascular conduits or structures includ-
„ Anterior skull base defects measuring greater than 1–2 cm— ing the facial nerve canal, otic capsule, and
particularly if (a) medial, (b) extending posteriorly through the ossicular chain. Associated skull base fractures
sphenoid planum and sinuses, and (c) associated with more
in other regions are seen in 47% of patients (3).
than 10 mL of traumatic pneumocephalus—are unlikely to
spontaneously resolve. In the traditional orientation-based nomen-
„ Surgical decompression is reported in one-fourth or less of pa- clature developed from cadaver experiments
tients with OAS and is performed infrequently or rarely in con- (12), 70%–90% of fractures are longitudinal
temporary practice. Early orbital apex decompression (within (ie, parallel to the petrous ridge) and 10%–30%
3 days) may be employed in patients with actively worsening are transverse (perpendicular) (2,13) (Fig 2).
visual acuity and displaced fracture fragments involving the
Comminuted fractures meeting both criteria are
optic canal; however, outcomes remain dismal irrespective of
the therapeutic approach.
considered mixed (14).
„ Transsphenoid fracture patterns are classified on the basis of
unique signatures of involved weak points, including the fora- CT-based Classification.—Temporal bone
men lacerum, sphenopetrosal fissure, petro-occipital fissure, HRCT includes the following: small field of
and occipitomastoid suture. view, high matrix size, bone kernel, submillime-
ter section thickness, and isotropic multiplanar
reformatted (MPR) images (2). With HRCT,
a large proportion of fractures do not fit neatly
Introduction into traditional systems (13). On MPR im-
Skull base fractures occur in 4%–30% of patients ages and three-dimensional renderings, 75% of
admitted with head injuries (1–4). The tempo- longitudinal fractures are shown to course in a
ral bone is involved in approximately 40% of 20°–30° off-axial oblique plane, bisecting the
patients, the orbital roof in 24%, the sphenoid external auditory canal (EAC) into upper and
bone in 23%, the occipital bone in 15%, and the lower halves before crossing the petrotympanic
ethmoid bone in 11% (5). Common causes of (glaserian) fissure and often resulting in foci of
skull base fracture include traffic accidents, falls, glenoid fossa gas (15). Vertically oriented longi-
assaults, and gunshot wounds (6,7). Improved tudinal fractures are uncommon (Fig 3). Mixed
survival in head-injured patients increases em- fractures have a widely variable prevalence,
phasis on skull base fracture management (1). ranging from 7% to 90% (15–17).
A range of complications is encountered, Inconsistencies in traditional fracture typ-
including cerebrospinal fluid (CSF) leak, en- ing and limited correlation with outcomes lead
cephalocele, meningitis, orbital apex syndromes to orientation-agnostic CT-driven classification
(OASs), facial nerve paralysis, hearing loss, and that distinguishes between otic capsule–violat-
cholesteatoma (8,9). In this article, CT fea- ing (OCV) and otic capsule–sparing (OCS)
tures and classification systems are presented fractures (Fig 4). OCV and apex fractures are
in relation to clinical decision making and termed petrous. Fractures termed nonpetrous are
management principles using the framework further subcategorized as mastoid or middle
of frontobasal, laterobasal, posterior basal, and ear, even though the middle ear is enveloped by
basioccipital (central clival) skull base frac- petrous bone (13). Mastoid fractures are more
tures (10,11). Surgical approaches to the skull peripheral and can involve the tegmen mastoi-
base are shown in Figure 1. Applied skull base deum and the mastoid segment of the facial
anatomy is reviewed in Appendix E1. Problem- nerve canal but do not traverse vital auditory
solving modalities, surgical preplanning, and structures (13). Various authors report a four- to
postoperative imaging are explored in greater eightfold increase in CSF leak prevalence with
depth in Appendix E2. High-resolution CT OCV fractures, a five- to ninefold increase in
764  May-June 2021 radiographics.rsna.org

Figure 1.  Approaches

to the skull base. Spe-
cific CT findings help
determine the surgical
team’s choice of expo-
sure. Repair of cerebro-
spinal fluid (CSF) leak,
facial nerve decompres-
sion, and resection of in-
vasive cholesteatoma af-
ter laterobasal fractures
are performed via trans-
temporal middle cranial
fossa (MCF) approaches
(T, light blue), trans-
mastoid approaches (M,
purple), or combinations of the two. Ossiculoplasty is performed through exploratory tympanostomy with an operating microscope.
Anterior skull base dural tear repairs and much less frequent optic nerve or orbital apex decompressions can be performed through a
frontal approach (Fr, red) via unilateral or bifrontal craniectomy. For fractures extending far posteriorly into the sellar-sphenoid plane,
bifrontal craniotomies can be extended to include the pterion (Pt, brown). “Craniofacial disassembly” techniques are subfrontal ap-
proaches that can obviate the need for brain retraction and spare the olfactory nerve if not severed by ethmoid-cribriform complex
fractures, but provide less exposure to ensure a watertight leak closure. A central transglabellar approach (G, gray overlay) is an option
for fractures resulting from frontal medial blows, and an extended subfrontal approach involving removal and replacement of the
frontal bar (FB, green) can potentially be used for orbital roof repair after frontal lateral blows. Widely adopted transnasal and emerg-
ing transorbital endoscopic approaches are also part of the surgeon’s armamentarium.

facial nerve injury, a seven- to 25-fold increase Although CT rarely depicts encephaloceles
in sensorineural hearing loss, and higher intra- directly (9), defects 1–2 cm in diameter strongly
cranial complication rates (3,13,16,18,19). suggest encephalocele that is unlikely to close
spontaneously, necessitating early dural repair
CT for Managing Complications (24,25) (Fig 5). Additional imaging with CT
or MRI cisternography may be needed with
CSF Leak.—CSF leak is encountered in up to multiple-defect fractures where the exact path
one-third of patients with basilar skull fractures of egress is unclear. Defects that are bilateral or
(13,20,21). Diagnostic algorithms and expectant present in different anatomic regions can con-
management principles are similar irrespective of found leak-site determination and selection of the
location. Grouping skull base fractures under the surgical approach (3,21,26) (Fig 6). Occasion-
umbrella term closed head injuries is misleading. ally, combined anterior and lateral exposures are
Most skull base fractures are open, with intra- necessary (21).
cranial contents exposed through the eustachian CT cisternography with intrathecal contrast
tube, nasopharynx, or sinonasal cavity or through material and noncontrast MR cisternography
tympanic membrane rupture (16,21). with a high-resolution heavily T2-weighted se-
Nonresolving leaks have a high risk of menin- quence help determine whether a given fracture
gitis without operative management (1,13,17), defect is a source of leak when ambiguity exists
with prevalence of meningitis reaching 23%– (see supplemental images in Appendix E2).
88% after 1–2 weeks and associated mortality of
1%–25% (11,22,23). Absence of otorhinorrhea CSF Leak: Considerations Specific to Laterobasal
does not allow exclusion of leak because brain Fractures.—OCV fracture is the strongest imaging
herniation, an intact tympanic membrane, blood predictor of CSF leak associated with laterobasal
clot, and mucosal swelling can obstruct drain- fractures (13,21). Patients have elevated risk of
age (23). CT cisternography is limited in utility meningitis throughout life, since the metabolically
for initial screening owing to leak intermittency inactive otic capsule heals through fibrous remod-
(9). HRCT alone has been shown to precisely eling (4,16) and does not take to layered closures
localize approximately 70% of fracture-related (16). Provided sensorineural hearing loss is pro-
leak sites (9). found with no serviceable hearing in the affected
CSF leaks from small (<1 cm diameter) ear, an aggressive meatal overclosure surgery
fracture defects can be treated expectantly for can permanently seal the cranial cavity (21). See
the first 7–10 days, with a 78%–95% rate of Appendix E2 for description and postoperative ap-
spontaneous closure using head-of-bed elevation pearances of meatal overclosure surgery.
and lumbar puncture to decrease pressure below In the presence of encephalocele through a
the tensile strength of the healing fibrous barrier large (>1–2 cm) tegmen defect, tegmen mastoi-
(10,11,16,20,21). deum fractures located posterolaterally near the
RG  •  Volume 41  Number 3 Dreizin et al  765

Table 1: Laterobasal (Temporal Bone) Fractures: Clinically Relevant HRCT Imaging Pearls by Compli-
cation
CSF leak
Defects <1 cm in diameter: managed expectantly (eg, head-of-bed elevation, stool softeners, lumbar drain) for
7–10 days
Defects >1–2 cm in diameter: unlikely to close spontaneously; encephalocele assumed
Posterolateral (tegmen mastoideum) defects: transmastoid surgical approach typically adequate
Anteromedial (tegmen tympani) defects: MCF approach avoids ossicles
Combined defects (tegmen tympani and tegmen mastoideum): combined transmastoid and MCF approach
avoids ossicles and facilitates retraction, débridement, and dural closure
OCV fractures in a nonhearing ear
  Lifetime increased risk of meningitis due to fibrous healing
  Meatal overclosure procedure to permanently seal off intracranial contents in a nonhearing ear
Facial nerve paralysis
Clinical examination may miss facial nerve injury in altered or obtunded patients
HRCT and electrodiagnostic tests provide precise data for objective decision making
HRCT fracture lines: used to determine surgical approach if ENoG or EMG reveals neurotmesis
  1. Perigeniculate, labyrinthine, or internal meatal: MCF approach
  2. Mastoid segment: transmastoid or combined transmastoid-MCF approach if concurrent with type 1 frac-
ture line above
  3. OCV fracture and no serviceable hearing: translabyrinthine approach with meatal overclosure considered
Persistent conductive hearing loss
Definitive diagnosis with audiometry (performed electively)
CT primarily useful for surgical planning after audiometry: type of reconstruction performed (PORP, TORP,
stapes piston)
CT in acute postinjury period: limited by hemotympanum; diagnosis of obvious disruptions (eg, incudomalleo-
lar separation; incus dislocation) helps ensure follow-up
Cholesteatoma
Diagnostically challenging, especially if there is extensive posttraumatic and postsurgical granulation tissue; both
HRCT and MRI are needed
HRCT allows inspection of FNC, tympanic cavity, ossicles, osseous labyrinth, sigmoid plate, and EAC
MRI: restricted diffusion is confirmatory of cholesteatoma
Two major types: EAC and implantation
  EAC cholesteatoma
   CT findings: inferior and posterior walls of EAC commonly eroded
   Treatment involves localized débridement and skin grafting with or without tympanoplasty
  Implantation cholesteatoma (gunshot wound or blast)
   CT findings: ossicle, FNC, and labyrinth involvement lead to perilymphatic fistula, CSF leak, meningitis,
and labyrinthitis ossificans
   Treatment in nonhearing ear with labyrinth involvement: mastoidectomy and meatal overclosure
Note.—EAC = external auditory canal, EMG = electromyography, ENoG = electroneurography, FNC = facial
nerve canal, MCF = middle cranial fossa, OCV = otic capsule–violating, PORP = partial ossicular replacement
prothesis, TORP = total ossicular replacement prosthesis.

pyramid base may require a different surgical Facial Nerve Paralysis.—The prevalence of fa-
approach than tegmen tympani fractures. Surgi- cial nerve palsies after temporal bone fracture is
cal goals are the same, involving necrotic brain 4%–7%, with 20%–25% being acute and com-
débridement and dural closure. For mastoid plete (13,21). Expectant management is appro-
defects, a complete mastoidectomy and fat graft priate for either delayed or incomplete palsies,
obliteration are performed (16,21,26). For tegmen since up to 94% of patients have self-limiting
tympani defects, an intracranial middle cranial contusion or traction injuries with recovery of
fossa (MCF) approach avoids interference with normal facial tone, symmetry, and eye closure
the ossicular chain. Combined mastoid and MCF (21). Immediate complete paralysis suggests
approaches are used for defects involving both the complete nerve trunk transection—the only
tegmen mastoideum and tegmen tympani (16). clear indicator of poor outcome (ie, permanent
766  May-June 2021 radiographics.rsna.org

Table 2: Frontobasal Fractures: Clinically Rel- Table 3: Posterior Basal Fractures: Clinically
evant HRCT Imaging Pearls by Complication Relevant HRCT Imaging Pearls by Complica-
tion
CSF leak
Defects <1 cm diameter: managed expectantly for Vascular injury
7–10 days CT angiography and CT venography are essen-
Defects >1–2 cm in diameter at CT: unlikely to tially mandatory
close spontaneously, especially if the following CT angiography features
factors are present   Longitudinal fractures
  Traumatic pneumocephalus >10 mL    Most common cause of basilar artery entrap-
 Comminution ment
  Central location (eg, tightly adherent dura at    Sharp clival bone ends also lacerate vertebral
ethmoid-cribriform complex) and basilar arteries
Operative approach    Cause lethal or unrecoverable brainstem
  Involvement of sellar-sphenoid plane: favors bi- infarct
frontal intradural approach; greatest exposure    Apnea test cannot be reliably performed in
  Far posterior sellar-sphenoid extension: bifrontal trauma patients with physiologic derange-
intradural approach and pterional cranioto- ments
mies can be combined    Brain perfusion studies may be necessary to
  Unilateral osseous defects: repair through unilat- confirm brain death
eral craniotomy may be possible CT venography features
  Recurrent CSF fistulas (small defects with   Dural venous sinus thrombosis
sclerotic margins): transnasal endoscopic ap-    Thrombosis seen in 41% of fractures through
proach highly efficacious dural venous sinuses
Orbital apex syndromes    7% have hemorrhagic venous infarct; anti­
Strong association with CCF and pseudoaneu- coagulation is administered unless contra-
rysm; ICA injuries common at C3 (lacerum)– indicated
C4 (cavernous) junction    Isolated sigmoid sinus thrombus unlikely to
  Liberal use of screening CT angiography cause infarct owing to collaterals (eg, infe-
  Endovascular repair with coils and stents rior petrosal sinus)
  Antiplatelet therapy if no bleeding-related con-    Temporal lobe infarct often from occlusive
traindication thrombus of sigmoid and proximal trans-
verse sinuses; obstructs drainage from vein
TON is the most devastating feature
of Labbé
  CT features: bone fragments displaced into
  Extra-axial hematomas
optic canal or superior orbital fissure
   Usually subdural or venous epidural in nature;
  MRI features: can show restricted diffusion of
monitored with serial head CT
optic nerve
   Surgical decompression and sinus repair may
  Surgery: decompression rarely performed; may
be necessary if rapidly expanding
be beneficial in alert patient with actively
worsening vision Cranial nerve (CN) palsies
Cranial nerve palsies self-limiting in great majority Common but spontaneously resolve as a rule in
of cases surviving patients
Transverse fractures most commonly associated
Note.—CCF = cavernous-carotid fistula, ICA = with CN III–CN VI palsies (stretch-impinge-
internal carotid artery, TON = traumatic optic ment)
neuropathy.
  CN VI palsy requires patching for diplopia
  Strabismus surgery is an option for rare non­
resolving cases
disfigurement)—necessitating decompression,   Carotid oculosympathetic plexus injury causes
reanastomosis, or graft repair (27,28) (Fig 7). partial Horner syndrome
Complete paralysis can be masked by traumatic   Diabetes insipidus and hypopituitarism may
brain injury, polytrauma, or hypnotics and muscle occur; require desmopressin analog, hydro­
cortisone, and levothyroxine
relaxants in 10%–15% of patients. This confounds
Clival fractures crossing jugular fossa (especially
differentiation of immediate from delayed onset
transverse and oblique)
(15,21). Therefore, objective data from HRCT
  High risk for jugular foramen syndrome (CN
and electrodiagnostic testing are critical (1,27,28). IX–CN XI palsy)
  May require temporary tracheostomy and gas-
Understanding Electrodiagnostic Testing.— trostomy for dysphagia (CN IX) and aspira-
Electrodiagnostic testing discriminates between tion risk
peripheral nerve neurapraxia, axonotmesis,
RG  •  Volume 41  Number 3 Dreizin et al  767

Table 4: Transsphenoid Fracture Pattern Recognition Using the West Classification System
Anterior transverse
Mechanism: medial frontal to temporal zone of impact
Orientation: coronal, always anterior to foramen lacerum
Landmarks: include sphenotemporal buttress, orbital roof or apex, jugum sphenoidale, and sphenoethmoidal
junction; may involve pterygoid plates
Variants: T-type fracture involves second dominant anterior sagittal fracture line through orbits
Posterior transverse
Mechanism: temporal to occipital zone of impact
Orientation: upside-down U shape, always involves sphenopetrosal fissure
Landmarks: include bilateral temporal bones (involvement of petrous temporal bone on at least one side) and
sphenoid body–clivus junction; may involve pterygoid plates on one side
Variants: may involve petro-occipital fissure and occipitomastoid suture on one side
Lateral frontal diagonal
Mechanism: zygomatic crest or superolateral orbit zone of impact
Orientation: always crosses midline from anterior impact to posterior
Landmarks: include sphenotemporal buttress, orbital roof or apex, sphenoid body, sphenopetrosal fissure, and
petrous temporal bone; may involve pterygoid plates contralateral to side of impact
Variants: can cross posteriorly through petro-occipital fissure and occipitomastoid suture; injury more severe if
fracture through sphenoid body and sella is oblique rather than coronal
Mastoid diagonal
Mechanism: mastoid process zone of impact; most severe transsphenoid fracture pattern; least common owing
to low survivability
Orientation: always crosses midline from posterior impact to anterior
Landmarks: include either occipitomastoid suture and petro-occipital fissure or petrous temporal bone and
sphenopetrosal fissure more laterally; fracture through sphenoid body is always oblique
Variants: anteriorly, orbital roof or apex, ethmoid bones, and jugum sphenoidale are variably fractured

Figure 2.  Three-dimensional

rendered images show clas-
sic examples of a longitudinal
fracture (arrows in left image)
and transverse fracture (arrows
in right image). Longitudinal
fractures begin in the posterior
squama, then course antero-
medially through the external
auditory canal (EAC), tegmen
tympani, epitympanum, os-
sicular chain, peri­ geniculate
region, and petrous carotid ca-
nal, terminating along the mid-
dle cranial fossa (MCF) near the
foramen lacerum. More exten-
sive fractures cross the Dorello
canal into the sphenoid body.
Transverse fractures result from
posterior parietal or more oc-
cipital blows, with fractures
extending from the foramen
magnum, through the petrous
pyramid and otic capsule, typi-
cally ending in the vicinity of the foramen spinosum within the greater wing of the sphenoid. In transverse fractures, involvement of
the ossicular chain is uncommon.

and neuro­tmesis. In neurapraxia, the nerve is tials can still be evoked. In axonotmesis, there is
stunned, failing to transmit voluntary action po- myelin breakdown. Wallerian degeneration results
tentials, but nerve connective tissue (endo-, peri-, from failure to transport key axonal proteins
and epineurium) remains intact. Action poten- beyond the injury, but connective tissue remains
768  May-June 2021 radiographics.rsna.org

Figure 3.  (a) Vertically oriented longitudinal fracture in a 41-year-old man with a ruptured right tympanic membrane and blood-
tinged otorrhea after a fall from a height. Three-dimensional (3D) image of the external cranial surface shows a vertically oriented
longitudinal fracture (arrows) entirely posterior to the petrotympanic fissure (*). (b) Obliquely oriented longitudinal fracture in a
61-year-old woman with a temporal bone fracture after a fall down stairs. The fracture line (arrows in left image) has an oblique orien-
tation, bisecting the EAC into upper and lower halves and crossing the petrotympanic fissure. On an axial image (right), the fracture
line has a classic longitudinal orientation (arrows). Oblique and vertical fractures are not distinguishable on axial images above the
petrotympanic fissure. Multiplanar reformatted and 3D images of the external cranial surface can be employed. The 3D orientation
of temporal bone fractures plays a role in the choice of surgical approach (discussed later).

Figure 4.  Otic capsule–violating (OCV) fracture

(arrow). OCV fractures represent a small fraction
of total temporal bone fractures but have highly
significant associations with major complications.
The preponderance of OCV fractures occur as the
result of longitudinal fractures, largely because of
the much higher overall frequency of the latter. CT
allows characterization of the otic capsule irrespec-
tive of fracture orientation, paving the way for more
clinically relevant anatomy-based classification.

intact, promoting orderly regrowth. In neurotme-

sis, connective tissue is disrupted, resulting in dis-
ordered nerve sprouting and scar (29). Wallerian
degeneration prevents transmission of electrical
impulses by 72 hours (2).
Electroneurography measures evoked com-
pound muscle action potentials noninvasively lines through the facial nerve canal ensures
at the orbicularis oculi and nasolabial crease in greater scrutiny, earlier testing, and early treat-
the early postinjury period (16). Diminution of ment with steroids (3).
compound action potentials by 90% over 3–6 days If early complete paralysis is unequivocal on
compared with the contralateral side is consistent the basis of clinical judgment or electroneurogra-
with neurotmesis (30). Beyond this period, intra- phy results, and HRCT shows facial nerve canal
muscular regeneration potentials measured with fracture, decompression and repair are performed
electromyography using a coaxial needle electrode as soon as clinically feasible (28). The decision to
are a marker of early neurologic recovery, while operate in the late period is made using HRCT
fibrillation potentials and sharp waves are signs of and electromyography (2,27,28) (Fig 8). Surgical
neurotmesis (28,29). Maximal filament growth decompression of the facial nerve canal is invasive,
and restoration of axoplasmic flow will occur at and 75% of patients with immediate-onset palsy
3–4 weeks—an ideal second window for diagnosis will recover without surgery (21). Electrodiagnos-
and late repair of facial nerve transection (2,28). tic testing and HRCT provide specific objective
Realistically, surgical repair is sometimes delayed data to reduce unnecessary surgery (27,28).
by months with good outcome (1,27,28).
HRCT for Surgical Preplanning.—HRCT has
Combining Electrodiagnostic Results with added value in determining the surgical approach
HRCT.—In obtunded patients, facial nerve pa- on the basis of fracture line location (27,28).
ralysis is easily missed (31). Bone spicules in the In otic capsule–sparing (OCS) fractures, sus-
facial nerve canal are appreciated at CT in only ceptible segments of the facial nerve are (a) the
about 18% of facial nerve injuries, with limited perigeniculate (~80%–93% of fractures) owing to
prognostic utility (27). Description of fracture traction at the greater petrosal nerve takeoff and
RG  •  Volume 41  Number 3 Dreizin et al  769

Figure 5.  Encephalocele in a 41-year-old man with a ruptured right tympanic membrane and blood-tinged otorrhea after a fall from
a height (same patient as in Fig 3a). (a) Coronal image shows a large (~2 cm) tegmen mastoideum defect (arrows) along the lateral
posterior ridge of the petrous pyramid. (b) Axial image shows a longitudinal fracture orientation (thin arrows), with the fracture line
coursing through the first genu of the facial nerve canal (thick arrow) and carotid canal (white *), beyond the foramen lacerum, and
into the sphenoid body, resulting in sphenoid hematosinus (black *). (c) Sagittal image shows a secondary fracture line (open ar-
row) entering the mastoid segment of the facial nerve canal (solid arrow) just above the canal for the chorda tympani (*). CT or MR
cisternography problem-solving modalities would not yield added value in this case with unambiguous correspondence between the
CSF leak and a single large defect at HRCT. Encephalocele was assumed, and repair was deemed necessary. Electroneurography of the
facial nerve additionally showed absence of evoked compound action potentials, consistent with nerve transection or neurotmesis.
Since the three-dimensional character of the fracture showed that fracture lines crossed both the mastoid and geniculate facial nerve,
decompression and repair were performed through a combined transmastoid and MCF approach. Dural repair performed through
the MCF approach included retraction of brain contents out of the bone defect, followed by bone grafting for defect closure. There
was no sizable tegmen tympani defect.

Patients with OCV fractures are potential

candidates for cochlear implantation if a cochlear
lumen can be identified or reestablished for
multi­array electrode introduction (27) (Fig 10).
Recovery of facial function after facial nerve
repair averages 7 months (3). Gold weight tarso­
rrhaphy can be used to restore eye closure during
prolonged periods of regrowth (Appendix E2).

Figure 6.  Subcentimeter tegmen tympani defect resulting Persistent Conductive Hearing Loss.—One-
from head trauma and temporal bone fracture in a 17-year-old fourth of temporal bone fracture patients will
girl. She previously underwent craniectomy and cranioplasty on have some degree of persistent sensorineural,
the left, and the right tegmen tympani defect was smaller than
1 cm. The tympanic membrane was intact, resulting in para-
conductive, or mixed hearing loss. In 80%, con-
doxical CSF rhinorrhea. The clinical circumstances resulted in ductive hearing loss is transient, resulting from
difficulty determining the site and side of the leak. High-resolu- hemotympanum or tympanic membrane perfora-
tion isotropic heavily T2-weighted MRI was used to definitively tion that resolves within 6 weeks (2,16).
confirm that the leak arose through the right tegmen defect
(see corresponding MR images for this figure in Appendix E2).
HRCT evaluation of the ossicular chain is
challenging acutely, since the finer segments of
the ossicles (eg, stapes and long or lenticular
(b) the mastoid (20%–25% of fractures) (27). In process of the incus) are typically obscured by
OCV fractures, facial nerve injuries nearly always ­hemotympanum (32). Incudostapedial disloca-
involve the labyrinthine segment. tion is the most common ossicular injury, so it is
Facial nerve injuries with perigeniculate or to be expected that many discontinuities will be
proximal (labyrinthine or meatal) fracture lines missed in this setting. Detection is still routinely
can be decompressed through an MCF approach possible for incudomalleolar separation (best
(Fig 9). This can be combined with mastoid ­visualized on axial images), dislocated incus
segment skeletonization using a transmastoid (2,32), and malleoincudal complex dislocation
approach if both regions are fractured (27,28). A (as an en-bloc dislocation on coronal images)
transmastoid-translabyrinthine approach is some- (32,33). Pneumolabyrinth is rare (33) and
times used for OCV fractures in patients with strongly suggests stapediovestibular dislocation
no serviceable hearing (16,21) (Fig 7). Radical with perilymphatic fistula (32,33) (Fig 11).
mastoidectomy-like meatal overclosure is used to A limited and rapid search for obvious le-
seal the cranial cavity. sions is appropriate at admission trauma CT to
770  May-June 2021 radiographics.rsna.org

Figure 7.  Transversely oriented OCV fracture (arrow) resulting from

a left temporal gunshot wound in a 23-year-old man. A bullet resided
within the region of the mesotympanum and the posterior prom-
ontory of the otic capsule, including the vestibule and semicircular
canals (inset). The patient was fully alert, and early complete facial
paralysis was diagnosed clinically. He had no serviceable hearing. A
transmastoid-translabyrinthine approach was used to decompress and
graft the perigeniculate and tympanic facial nerve segments. Mastoid-
ectomy with meatal overclosure was subsequently performed to mini-
mize the risk of CSF leak or meningitis after otic capsule violation and
labyrinthectomy and reduce the likelihood of future cholesteatoma
from gunshot wound–related implantation of keratinous stratified
squamous epithelium.

Figure 8.  Nerve transection or neurotmesis in a 19-year-old man with a gun-

shot wound to the left temporal bone. Three-dimensional (3D) reformatted im-
age shows the 3D course of the bullet through the left zygoma (black arrow),
glenoid fossa, EAC (white arrow), and mastoids (arrowhead). Coronal HRCT im-
age (inset) shows complete disorganization of the left EAC, middle ear, and mas-
toids. After a several-week course during which other injuries were addressed,
electromyography results were consistent with nerve transection or neurotmesis.
The patient underwent mastoidectomy with a meatal overclosure procedure in-
volving removal of all squamous epithelium, ossicles, and tympanic membrane
and oversewing of the EAC to mitigate the risk of subsequent invasive implanta-
tion cholesteatoma. The mastoid segment of the facial nerve was transected.
The intact proximal segment was grafted to the main trunk of the facial nerve
proximal to the initial division of the pes anserinus.

help prevent loss to follow-up, which is com- With regard to preoperative planning, otos-
mon in hearing loss patients. Average delays copy is not a perfect reference standard, and CT
to ossicular repair are as high as 6 years (34). has added value for planning initial or revision
HRCT will have the greatest utility for evaluat- ossicular reconstruction (Appendix E2). Persis-
ing ossicular chain discontinuities if performed tent sensorineural hearing loss and vestibular
around the same time as audiometric assess- symptoms often have causes that are occult at
ment once hemotympanum or otorrhagia CT—including cochlear concussion—and are
has receded and the tympanic membrane has beyond the scope of this work.
healed (32). The decision to perform explor-
atory tympanostomy in patients with no severe Cholesteatoma.—Implantation cholesteatoma is
impairment in the contralateral ear is based on described in 5%–10% of military blast or gunshot
an air-bone gap of 30 dB or greater at audi- wound–related temporal bone fractures (36,37)
ometry, which is highly specific for ossicular (Fig 12). Localized EAC cholesteatoma can rarely
discontinuity in the trauma setting. From a de- occur as a complication of displaced EAC frac-
tection standpoint, imaging plays a supportive tures (Fig 13). Long-term monitoring is necessary,
or confirmatory role (35). as cholesteatoma may occur many years later (37).
RG  •  Volume 41  Number 3 Dreizin et al  771

the ossicular chain, facial nerve, and labyrinth

(16). If the labyrinthine wall is eroded, perilym-
phatic fistula may result (38). As with OCV frac-
tures, labyrinthitis ossificans may develop from
recurrent infection (Fig 12). Tegmen dehiscence
also causes CSF leak and meningitis (38,39).
Well-aerated mastoids in trauma patients are
more permissive to extensive cholesteatoma
than those in patients with chronic middle ear
disease (37), and traumatic cholesteatomas may
be considerably more extensive than suggested
by physical examination or symptoms (39). In
advanced cases with intracranial extension, ero-
sion of the sigmoid plate and sinus thrombosis
Figure 9.  Neurotmesis in a 40-year-old man with a mixed can occur (38).
otic capsule–sparing (OCS) temporal bone fracture, with Management involves débridement of ne-
fracture lines crossing the perigeniculate facial canal (arrow)
crotic bone and skin grafting to prevent disease
as well as the mastoid segment. There were no volitional
action potentials or regeneration potentials at electromy- progression for localized EAC cholesteatoma
ography, consistent with neurotmesis. Facial nerve decom- and may involve surgical widening of the canal
pression was performed with a combined transmastoid (ie, canaloplasty and meatoplasty). Tympano-
and MCF approach. The mastoid facial nerve segment was
plasty using temporalis fascia is performed for
skeletonized, and the geniculate facial nerve was decom-
pressed through the MCF approach by drilling medially and tympanic membrane invasion (40). An initial
laterally from the facial hiatus. attempt may be made at gradually widening a
lateral EAC stenosis using sponges or stents
(16). CSF leak resulting from a cholesteatoma is
addressed with meatal overclosure surgery (37).

Frontobasal Fractures

Classification Systems
Frontobasal fractures can vary from single soli-
tary small linear fractures to complex extensive
comminuted fractures (8,10,23,41). Use of
Figure 10.  Encephalocele in a 24-year-old man with a remote multiplanar reformatted images is compulsory
history of traumatic brain injury, profound right-sided hear- when evaluating the anterior skull base planes
ing loss, and no hearing on the left. CT image obtained for (8,41). The adequacy of surgical exposure is the
surgical planning before placement of a left cochlear implant
shows a large left tegmen tympani and tegmen mastoideum
most important factor in successful closure of
defect (arrow). Encephalocele would require additional MCF dural tears, and the type and extent of exposure
exposure for retraction and necrotic brain tissue débridement. are largely planned by determining the skull
The presence of encephalocele was therefore confirmed with base planes involved using CT (42). These along
MRI. After mastoidectomy and advancement of the multiarray
cochlear implant through the facial recess and round window
with relevant sinonasal and orbital anatomy are
into the middle turn of the cochlea, closure with a combined reviewed in Appendix E1.
transmastoid-MCF approach with a dural graft was performed Since patients are frequently obtunded or co-
(Appendix E2). matose, decisions regarding surgical timing and
operative approach for frontobasal fractures are
dependent on CT features: specifically, the skull
Traumatic cholesteatomas result from invagi­ base planes involved (orbital roof, ethmoid-
nation or implantation of keratinous stratified cribriform complex, and sellar-sphenoid body
squamous epithelium (37). Sloughing of keratin plane) and their number, laterality, and poste-
creates a central cyst and surrounding peri- rior extent (23). Raveh et al (42) introduced a
matrix—a vascularized inflammatory tissue in still-endorsed frontobasal fracture classification
reaction to keratin debris that releases proteo- system (8,42) with two broad injury categories.
lytic enzymes (37–39). The inferior and poste- Type 1 fractures are limited to the frontal vault
rior walls of the EAC are commonly eroded in and naso-orbitoethmoid (NOE) regions. The
localized cases, and sequestered bone debris is a posterior wall of the frontal sinus, anterior skull
characteristic CT feature (39). base planes, and dura remain intact (42). Such
Traumatic cholesteatomas can also reside in fractures are treated using established principles
the tympanic cavity and mastoid and may involve of facial reduction and fixation (43).
772  May-June 2021 radiographics.rsna.org

Figure 11.  Ossicular chain discontinuities. A, Otic capsule–sparing (OCS)–type temporal bone frac-
ture with ejection of the left incus into the EAC (arrow) in a 52-year-old man who fell. B, Incudomal-
leolar complex dislocation in an 18-year-old man after a motorcycle collision. The malleus is seen
displaced inferiorly into the mesotympanum (arrow). C, Nonpetrous (OCS) fracture with middle ear in-
volvement and incudomalleolar separation (arrow) in an 18-year-old patient who fell out of a car. Inset
shows the contralateral normal-appearing incudomalleolar joint for comparison. D, Stapediovestibular
dislocation and perilymphatic fistula in a 29-year-old man who was found down (same patient as in
Fig 4). CT image shows a transversely oriented OCV-type fracture extending through the oval window
niche with a focus of gas in the vestibule and possible intrusion of the faintly seen stapes superstructure
(arrow), consistent with stapediovestibular dislocation and perilymphatic fistula.

This work focuses on type 2 fractures (true

anterior skull base fractures) involving combi-
nations of skull base planes, depending on the
direction and severity of transmitted forces.
To varying degrees, medial blows propagate
through the cribriform-ethmoid complex and
sellar-sphenoid body plane, and lateral blows
involve the orbital roofs and apices (11).

Role of CT in Managing Complications

CSF Leak Considerations Specific to Fronto-

basal Fractures.—Dural defects are the leading
indication for surgery after anterior skull base
fractures (9). CSF leaks occasionally result from
Figure 12.  Invasive implantation cholestea-
subtle fovea ethmoidalis fractures after relatively toma with erosion of the labyrinthine wall (white
low-energy mechanisms and can be easily missed arrow), perilymphatic fistula, and recurrent laby-
(23,25). Owing to tight adherence between bone rinthitis ultimately leading to labyrinthitis ossifi-
and dura, there is strong correspondence between cans (black arrow) in a 38-year-old man with a
remote right temporal gunshot wound. He pre-
a CSF leak and CT defects at the ethmoid-cribri- viously underwent mastoidectomy and an EAC
form complex (9,25) (Fig 14). overclosure procedure. See Appendix E2 for fur-
Frontobasal fracture–related CSF leak ther characterization of posttraumatic and post-
manifests at a rate five to six times higher than operative cholesteatoma recurrence using MRI.
in fractures of the middle and posterior fossa
RG  •  Volume 41  Number 3 Dreizin et al  773

better definition of contused brain, avoid resect-

ing normal brain tissue, and minimize seizure
risk from vigorous frontal lobe retraction (10,11).
Because recurrent CSF leak may occur months
to years later from disruption of adhesions and
fibrotic tissue in the course of daily activity, long-
term follow-up is prudent in nonoperatively man-
aged patients (7,23,41). Spontaneous-appearing
meningitis after remote head trauma raises the
possibility of an undiagnosed slow leak (2). CT
may reveal a small defect with sclerotic margins
and pneumocephalus years to decades after in-
jury (47) (Fig 14).
Figure 13.  EAC cholesteatoma in a 28-year-old woman
with a history of remote temporal bone fracture with
persistent step-off of the EAC floor and EAC stenosis.
Surgical Approaches.—The neurosurgeon at-
The cholesteatoma perimatrix causes erosive changes in tempts to minimize stress to brain parenchyma
the floor of the EAC and contains characteristic intramu- and preserve the olfactory nerve when possible
ral bone debris (white arrow). The cholesteatoma may (10). However, sufficiently wide exposure is
have originally resulted from invagi­nation of keratinous
stratified squamous epithelium into a fracture defect
necessary to reliably repair dural defects, and
within the EAC floor (black arrow). The cholesteatoma the olfactory nerve is commonly already severely
exerted mass effect on and invaded the tympanic mem- damaged from trauma. Broadly, two open tech-
brane, requiring canaloplasty, meatoplasty, and tympa- niques are described in the literature as provid-
noplasty with fascial grafting. A small tegmen tympani
defect was incidentally noted but was not associated
ing adequate exposure to simultaneously repair
with any CSF leak or recurrent meningitis. The diagnosis the anterior skull base dura and decompress the
of EAC cholesteatoma was confirmed with MRI, which orbital apex when needed: these include trans-
showed ­restricted diffusion (not shown). frontal intradural approaches and less common
olfactory nerve–sparing subfrontal extradural
“craniofacial disassembly” exposures (10,20).
A transfrontal intradural approach with bi­
frontal craniotomy provides extensive access for
placement of dural grafts and orbital roof mesh
implants. This approach is of greatest benefit
when CT demonstrates extensive bilateral
displacement and comminution of ethmoid-
cribriform complex and orbital roof planes with
far posterior extension of fracture lines into the
sellar-sphenoid region (7,41). If the CT frac-
ture pattern is mostly limited to anterior defects
on one side, a unilateral craniotomy may be
Figure 14.  CSF leak in a 64-year-old woman with recur-
sufficient (7,23). The transfrontal intradural
rent meningitis from remote skull base trauma. Coronal CT
image shows a narrow CSF fistula with smooth sclerotic approach provides simultaneous decompression
margins within the cribriform plate and medial fovea eth- of the neurocranium in cases exhibiting hernia-
moidalis (arrows). The CSF leak was confirmed with heavily tion (8).
T2-weighted fat-saturated MR cisternography (see supple-
Subfrontal approaches involve disassembly of
mental MR images, Appendix E2). The patient underwent
transnasal endoscopic repair with removal of necrotic bone the glabella and nasal pyramid and exenteration
and defect closure with dural graft. of the ethmoids and sphenoethmoidal recess for
access to central ethmoid-cribriform complex
and sellar-sphenoid body region dural defects.
(11,23). Most cases (~85%) are self-limiting Extended exposures include the superior orbital
(7,23,44). Anterior skull base defects measuring rims (7,8,20,42). Removal of the entire frontal
greater than 1–2 cm—particularly if (a) medial, bar facilitates orbital roof repair with minimal
(b) extending posteriorly through the sphe- brain retraction (42).
noid planum and sinuses, and (c) associated Occasionally, subfrontal and transfrontal ap-
with more than 10 mL of traumatic pneumo- proaches are combined (Fig 16). Analogous nasal
cephalus—are unlikely to spontaneously resolve endoscopic techniques are highly efficacious for
(7,23,25,45,46) (Fig 15). small medially localized slow-flow ethmoid, crib-
Surgeons often delay transfrontal intradural riform, and sellar defects (8,20) (Fig 14). Rela-
repairs until cerebral edema subsides to allow tively novel transorbital neuroendoscopic surgery
774  May-June 2021 radiographics.rsna.org

Figure 15.  Clinically obvious sinonasal CSF leak in a 24-year-old woman with left-sided midfacial fractures after
a motor vehicle collision. (a) CT image shows fracture extension across the midline to the right sellar-sphenoid
body (arrow). (b) Top-down three-dimensional reconstruction shows severe comminution of the left orbital
roof (open arrow), ethmoid-cribriform complex (*), sellar-sphenoid plane (thick solid arrow), and bilateral or-
bital apices (thin solid arrows) resulting from combined upper medial and lateral force transmission. A wide left
frontal-temporal craniectomy was used to provide generous access. Repair was performed with dural grafting.
Titanium mesh was used to cover the left orbital roof blow-up fracture and apex after repositioning fragments.
The CSF leak resolved, and some limited vision in the left eye was preserved. Postoperative supplemental images
are included in Appendix E2.

Figure 16.  Fractures resulting from bilateral medial and lateral frontal force transmission in a 23-year-old man
who fell from a balcony. Top-down three-dimensional reconstruction (left) and anteroposterior view of panfacial
fractures (right) show that the fractures include all major planes (bilateral orbital roofs, ethmoid-cribriform plate
complex, and sellar-sphenoid body plane). This necessitated a bifrontal approach. A large dural tear predomi-
nantly involving the central planes extended posteriorly to the sella turcica. The dural tear was patched with a
cadaveric tissue allograft. The orbital roofs were then repaired by maxillofacial surgeons through an extended
subcranial approach. (See supplemental postoperative images in Appendix E2.)

(TONES) (20) employs supraorbital keyhole Superior Orbital Fissure Syndrome.—SOFS

craniotomies for access to defects in the lateral involves injury to any permutation of neurovas-
fovea ethmoidalis and orbital roof. cular structures transmitted through the supe-
rior orbital fissure, either passing through the
Orbital Apex Syndromes.—Traumatic orbital annulus of Zinn (cranial nerve [CN] III, CN
apex syndrome (OAS) encompasses a spectrum V1 [nasociliary branch], CN VI) or outside of it
of cranial nerve, optic nerve, and vascular lesions (CN IV, CN V1 [frontal and lacrimal branches],
divided by anatomic location into three groups: superior orbital vein) (48) (Appendix E1). Signs
superior orbital fissure syndrome (SOFS), true and symptoms of SOFS include multiple cra-
OAS, and cavernous sinus syndrome (CSS) nial nerve palsies with complete or incomplete
(42,48–50). ophthalmoplegia and diplopia (CNs III, IV, and
RG  •  Volume 41  Number 3 Dreizin et al  775

of obviously displaced bone fragments imping-

ing on the superior orbital fissure and optic
canal at CT (10) (Fig 17). Relative afferent pu-
pillary defect (RAPD), a hard sign of traumatic
optic neuropathy, may be seen in true OAS.
High-resolution MRI aids in evaluation of trau-
matic optic neuropathy but is not always feasible
in obtunded severely injured patients during the
short window when surgical decompression may
be beneficial (51) (Appendix E2).
Historically, OASs have been underreported,
and surgical treatment is controversial, without
well-established therapeutic protocols (48,52).
Surgical manipulation is risky and can poten-
tially exacerbate optic nerve injury (42). Conse-
quently, surgical decompression is reported in
one-fourth or less of patients with OAS and is
performed infrequently or rarely in contempo-
rary practice (48).
Early orbital apex decompression (within 3
days) may be employed in patients with actively
worsening visual acuity and displaced fracture
fragments involving the optic canal (53); how-
ever, outcomes remain dismal irrespective of
Figure 17.  Loss of vision in a 22-year-old patient
within 1 hour after an assault. Axial (a) and coronal (b) the therapeutic approach. The orbital apex is
CT images show a lateral frontal fracture that results in decompressed via transfrontal approaches by
narrowing of the optic canal and apex cone (arrow). optic roof and sphenoid ridge fragment removal
Transnasal endoscopic decompression was performed 1 (8), and via subfrontal or endoscopic techniques
day after injury. Supplemental postoperative images are
shown in Appendix E2. by removal of the posterior-most lamina papyra-
cea at the apical orbital cone (23,42,54). Some
superior orbital fissure decompression occurs
VI), miosis or mydriasis and ptosis (CN III, indirectly with reduction of facial fractures ex-
oculosympathetic carotid plexus), and decreased tending to the greater sphenoid wing.
corneal reflex, lacrimal hyposecretion, or upper
facial sensory disturbance (CN V [ophthalmic OAS-associated Vascular Injuries.—Head and
and maxillary divisions]). neck CT angiography is used liberally as a
screening tool after skull base fractures. Neuro-
True OAS.—True OAS is thought to require surgeons also request CT angiography if plan-
greater force transmission, is characterized by ning decompressive craniectomy to exclude
more severe cranial nerve palsies (48), and is potentially explosive active bleeding (55).
distinguished from its variants by sudden or pro- Internal carotid artery (ICA) injuries occur
gressive loss of visual acuity from traumatic optic in only 2.6% of skull base fractures overall but
neuropathy. The prognosis is poor, with two- are three to four times as common with carotid
thirds of cases resulting in complete blindness or canal involvement. Surprisingly, the petrous ICA
visual acuity of light perception only (42,48). segment is rarely injured (56). Most injuries
occur at the turn formed by the lacerum (C3)
Cavernous Sinus Syndrome.—CSS results from and cavernous (C4) segments about the spheno-
an injury involving the endocranial surface of occipital junction (56). Associated OAS is com-
the orbital apex and cavernous sinus. The same mon, and most injuries are cavernous-carotid
spectrum of cranial neuropathies seen with fistulas and pseudo­aneurysms (48,56).
SOFS are coupled with sensory loss involving The imaging manifestation of cavernous-
the maxillary division (CN V2) of the trigeminal carotid fistula includes prominent early filling
nerve, which exits the skull base through the fo- and enlargement of the affected cavernous sinus
ramen rotundum and pterygopalatine fossa (48). at CT angiography (Fig 18). Other findings
Realistically, symptoms of cranial palsy are include proptosis, engorged ipsilateral superior
often masked by some combination of primary ophthalmic vein, and enlarged inferior petrosal
coma, facial swelling, and ocular injury (10). sinus (46). Endovascular techniques including
Initial suspicion is often based on the presence coils, stents, flow diverters, and balloon occlusion
776  May-June 2021 radiographics.rsna.org

have replaced surgical management (56). Massive

bloody otorrhea or rhinorrhea is rare but warrants
urgent angiographic balloon occlusion (16,56).

Anosmia.—Bilateral olfactory nerve injury causes

hyposmia or permanent complete anosmia in as
many as 91% of patients with frontobasal frac-
tures (57). The diagnosis is strongly suggested by
comminution and displacement of the ethmoid-
cribriform complex at CT, but the definitive
diagnosis is made using an odor discrimination
test and endoscopic examination to exclude an
obstructive cause (57). Anosmia greatly affects
quality of life, and there is no viable surgical Figure 18.  Orbital apex syndrome (OAS) in a 37-year-
old man. Contrast-enhanced CT image shows bilateral
treatment. Only 10% of patients with traumatic early filling of the cavernous sinus (arrows), consistent with
anosmia spontaneously recover sense of smell. cavernous-carotid fistula. Supplemental images from digital
subtraction angiography (DSA) before and after treatment
Posterior Basal Fractures are shown in Appendix E2.
Posterior basal fractures can involve the basi­
occiput (clivus) centrally, the squamous occipi-
tal bone bearing the torcular impression and
transverse sinus groove, and the lateral (condy-
lar) occipital bone. The condylar part features
the hypoglossal canal, the posterior portions of
the jugular foramen, and the sigmoid notch.

Classification
The Corradino CT-based classification for
basioccipital fractures employs three categories:
longitudinal (Fig 19), transverse (Fig 20), and
oblique (Fig 21) (58). Longitudinal fractures Figure 19.  Longitudinal-type clivus fracture (arrows) in a
result from midsagittal or vertex blows, while 26-year-old man with a traumatic brain injury after a motor
transverse or oblique fractures result from bilat- vehicle collision. Cranial neuropathies included right trigeminal
neuralgia that gradually subsided over 14 months and a right-
eral crush. Mortality is highest for longitudinal sided facial nerve injury without associated temporal bone
fractures at 67%, compared with 40%–50% for fracture that resulted in persistent synkinesis. The mechanism
transverse and oblique fractures. The three types responsible is thought to involve stretch impingement at the
are relatively evenly distributed (58). Meckel cave and the cisternal segment of the facial nerve as
the brain moves posterosuperiorly during deceleration injury.
The patient was managed conservatively with neuropathic
Complications and Management pain medications.
Fractures involving the basiocciput are rare but
highly lethal owing to the extreme forces involved,
the proximity to the brainstem, and the high in- Subtle clivus fractures may initially manifest as a
cidence of vascular injury (59). Both CT angiog- retroclival venous epidural hematoma (63).
raphy and CT venography are mandatory. Clival
fracture fragments have sharp bone ends that Occipital Fracture–associated Cranial Nerve
cause arterial injury through tears in the retro­clival Palsies.—Cranial neuropathy is described in
dura (Fig 20). Basilar artery entrapment between 14%–100% of basiocciput fractures (59,64).
fracture fragments is more typically associated Spontaneous resolution within weeks to months
with longitudinal fractures and causes brainstem is common, particularly for motor nerves and
infarct, which is fatal or exhibits no functional with delayed onset. Both upper and lower cranial
recovery (60,61). nerve palsies can occur with clival fractures.
Bilateral pontine hemorrhage is virtually CN III–CN VI palsies are more characteristic of
always lethal (62). An apnea test, the clinical transverse clival fractures (58,59). Patients with
sine qua non of brain death, cannot be reliably abducens (CN VI) palsy from stretch impinge-
performed in trauma patients due to acid-base ment at the Dorello canal usually recover be-
disturbances, hypothermia, volume overload, or tween 2 weeks and 4 months (65).
neuromuscular blocking agents, and a brain per- Eye patching is used to rehabilitate the paretic
fusion study may be necessary for confirmation. eye, and strabismus surgery is considered with no
RG  •  Volume 41  Number 3 Dreizin et al  777

Figure 20.  Clivus fracture in a 54-year-old woman after a mo-

tor vehicle collision. Solid arrows indicate a comminuted trans-
verse fracture through the tip of the clivus, with bone ends
displaced through disrupted dura abutting the V4 segments of Figure 22.  Jugular foramen syndrome in a
the vertebral arteries. Laceration by sharp bone ends resulted in 37-year-old female restrained driver whose car
a lobular pseudoaneurysm at the junction with the right poste- was rear-ended by a tractor trailer at speed. She
rior inferior cerebellar artery (PICA) (open arrow). The pseudo­ sustained a comminuted predominantly trans-
aneurysm was successfully coil embolized. verse basioccipital fracture, with fragments dis-
placed into the pars vascularis and pars nervosa
of the left jugular foramen (arrow). The patient
had classic findings consistent with jugular fora-
men syndrome, including dysphonia, vocal cord
weakness, and dysphagia requiring a percutane-
ous gastrostomy for temporary enteral feeding.
The palsies resolved completely within 9 months
after the injury.

laterally through the jugular fossa (28,67,68) (Fig

22). Since both the temporal bone and the lateral
occiput form the jugular fossa, a fracture through
either region may be causative (13,28). Patients
may develop dysphonia from ipsilateral vocal cord
paralysis, dysphagia, and paralysis of the ipsilateral
trapezius and sternocleidomastoid muscles (46).
Temporizing measures may include tracheostomy
Figure 21.  Oblique basioccipital fracture in a 56-year-old and percutaneous gastrostomy (69).
woman who fell and impacted her head against the wall at the
foot of a flight of stairs. She had bilateral oto­rrhagia and was Diabetes insipidus is rare after basiocciput
unresponsive, with a Glasgow Coma Scale score of 3. Head CT fractures and usually regresses spontaneously in
showed diffuse loss of gray-white differentiation, transtentorial surviving patients bridged with hormone replace-
herniation, and obliteration of the suprasellar and perimesen- ment therapy (27,59).
cephalic cisterns, consistent with anoxic brain injury. HRCT im-
age of the skull base shows an oblique basi­occipital fracture Occipital condyle fractures are associated with
(arrows) traversing both temporal bones. An apnea test could hypoglossal nerve palsy, which is usually delayed
not be reliably performed. Therefore, the patient underwent in onset from callus formation or condylar frag-
cerebral perfusion scintigraphy, which showed absent blood ment migration (69,70) (Fig 23). Hypoglossal
flow, confirming the clinical diagnosis of brain death. (See
supplemental figure in Appendix E2.) nerve palsy results in ipsilateral tongue deviation
and hemiatrophy (46).

recovery. CN V palsy from stretch impingement at Vascular Injuries.—CT venography is appropriate

the Meckel cave entrance is rare, seen only along- for any skull base fracture that traverses the dural
side bilateral CN VI or CN VII palsies. Partial sinuses or jugular bulb, depicting traumatic throm-
Horner syndrome (miosis and ptosis) may result bosis in up to 41% of patients (71,72). Seven per-
from carotid oculosympathetic plexus injury in cent of these patients develop hemorrhagic venous
patients with carotid injury (16,48,50,66). Sponta- infarcts (71). Exploration is usually not warranted
neous recovery is the norm. for isolated sigmoid sinus thrombus, since there
Jugular foramen syndrome (palsies of CN is rich collateral return from the inferior petrosal
IX–CN XI) is the most common clinical com- sinus, but may be necessary for more extensive
plication of basiocciput fractures propagating thrombus. Since the inferior anastomotic vein (vein
778  May-June 2021 radiographics.rsna.org

Figure 23.  Cranial nerve (CN) XII palsy in a 33-year-old

man with a large axial loading–type condylar fracture af-
ter a motor vehicle collision. Image shows a fracture line
extending into the hypoglossal canal (arrow). The patient
developed persistent CN XII palsy, with ipsilateral tongue
deviation at examination and dysarthria. Management
is almost always conservative. The condylar fracture was
treated with a halo device.

Figure 24.  Temporal lobe venous infarction in a 63-year-old man who fell from a standing position.
(a) Axial CT venogram shows a left temporal oblique fracture (similar to the example shown in Fig 3b)
crossing the sigmoid groove and jugular foramen, with resultant thrombosis of the distal transverse sinus,
sigmoid sinus (arrow), and jugular bulb. (b) Axial CT image shows a corresponding hemorrhagic venous
infarct in the left temporal lobe (arrow), which is drained by the vein of Labbé (inferior anastomotic vein), a
superficial tributary of the thrombosed distal transverse sinus. The sinus thrombosis diminished and became
nonocclusive within 10 days of anticoagulation. A supplemental MR image is provided in Appendix E2.

of Labbé) drains into the transverse sinus along of weakness—analogous to the Le Fort lines of
the lateral surface of the brain, the temporal lobe is least resistance in midfacial fractures—with the
a relatively common site of venous infarction (Fig sellar-sphenoid region as a central way station.
24). Anticoagulation is used unless contraindicated Major sphenoid landmarks and points of weakness
by other severe injuries (3,46,72). through the sphenoid are illustrated in Appendix
Extra-axial hematomas occurring in the poste- E1. Tremendous forces are necessary; therefore,
rior fossa are almost always sequelae of fracture. neurovascular complications are more numerous
These are usually subdural or venous epidural and severe but are otherwise modular combina-
collections. Expansion is typically slow and can tions of complications attributed to the fronto-
be monitored with serial head CT (46,73,74). A basal, laterobasal, and posterior basal regions. The
rapidly enlarging hematoma with worsening mass West classification (75) provides a useful bird’s-eye
effect mandates decompression and possible view for rapid synthesis of diagnostically challeng-
dural venous sinus repair (10) (Fig 25). ing injuries and correlates with mortality.
Four patterns are described: anterior trans-
Transsphenoid Fractures verse, posterior transverse, lateral frontal diagonal,
Transsphenoid fractures (75) cross the skull base and mastoid diagonal (Table 4). Transsphenoid
laterally or diagonally through reproducible lines fracture patterns are classified on the basis of
RG  •  Volume 41  Number 3 Dreizin et al  779

Figure 25.  Rapidly enlarging extra-axial posterior fossa hema-

toma in a 49-year-old pedestrian who was struck. Fracture through
the posterior and lateral occiput resulted in the hematoma. Axial
image shows the hematoma (arrows) with life-threatening mass
effect, manifesting as effacement of the perimesencephalic cis-
terns, tonsillar herniation, and superior transtentorial cerebellar
herniation. The fractures and suboccipital craniotomy are depicted
on a supplemental postoperative image in Appendix E2.

Figure 26.  The anterior transverse fracture pattern characteristically involves the squamous temporal bone (1),
spheno­temporal buttress (2), orbital roof and apex (3), jugum sphenoidale (4), and sphenoid-ethmoid junction (5).
The pterygoid plates are variably involved (6). There is a wide potential zone of impact, ranging from medial frontal to
temporal. Zygomaticomaxillary complex (ZMC) and naso-orbitoethmoid (NOE) fractures are common. Fracture lines
are always anterior to the foramen lacerum. (See Table 4.)

unique signatures of involved weak points, includ- Posterior transverse fractures have a temporal
ing the foramen lacerum, spheno­petrosal fissure, or occipital zone of impact and a characteristic
petro-occipital fissure, and occipitomastoid suture. upside-down U shape (Fig 27), crossing both
Diastatic fissures and oblique-diagonal orientation temporal bones and sphenopetrosal fissures and
through the sellar-sphenoid body plane (especially the sphenoid body–clivus junction. Temporal
common in the lateral frontal diagonal and mas- bone fractures are petrous on at least one side.
toid diagonal patterns) confer greater severity and A variant involves unilateral extension through
worse outcomes. The mastoid diagonal pattern is a petro-occipital fissure and occipitomastoid
particularly lethal. suture.
Anterior transverse fractures are co­ronally Lateral frontal diagonal and mastoid diagonal
oriented with a wide point of impact from the fractures have frontolateral or occipitomastoid
medial frontal bone to the anterior temporal zones of impact, respectively, and always cross
bone. These involve the sphenotemporal buttress the midline. Anteriorly, there is involvement of
laterally and the jugum (planum) sphenoidale the same points encountered in the classic or
and sphenoethmoidal junction medially. Fracture variant anterior transverse fracture on one side;
lines are always anterior to the sphenopetrosal fis- posteriorly, fracture lines follow either the petro-
sure (Fig 26). A T-type variant involves a second occipital fissure and occipitomastoid suture more
sagittal paramedian fracture line. Zygomatico­ medially or the sphenopetrosal fissure and tem-
maxillary complex (ZMC) and naso-orbito­ poral bone more laterally (Figs 28, 29). Pterygoid
ethmoid (NOE) fractures are common. plate involvement is common (75).
780  May-June 2021 radiographics.rsna.org

Figure 27.  Posterior transverse fractures

have an upside-down U shape and character-
istically involve the posterior sphenoid-clivus
junction (1), sphenopetrosal fissure (2), and
both temporal bones (3) (the fracture must
involve the petrous bone on at least one
side). A variant involves the petro-occipital
fissure and occipitomastoid suture (4). The
pterygoid plates may be involved on one
side. The zone of impact ranges from the pos-
terior temporal bone to the occipital bone.
The fracture resembles a transverse clivus
fracture as described in the Corradino classi-
fication, but the central fracture line is more
anterior. (See Table 4.)

Figure 28.  Lateral frontal diagonal fractures cross the midline from anterior impact to posterior. Major land-
marks include the sphenotemporal buttress (1), orbital roof and apex (2), sphenoid body with a coronal (3) or
(more severe) oblique (4) orientation, sphenopetrosal fissure (5), and petrous temporal bone (6). The zone of
impact occurs at the zygomatic crest (ie, the zygomaticomaxillary buttress) or superolateral orbit. Variants may
involve the petro-occipital fissure and occipitomastoid suture and the jugular fossa or foramen. The fracture may
involve the contralateral pterygoid plate (7). (See Table 4.)

Figure 29.  Mastoid diagonal fractures cross

the midline in the posterior to anterior direc-
tion. Landmarks include the occipitomastoid
suture (1), petrous temporal bone (2), spheno-
petrosal fissure (3) (or alternatively the petro-
occipital fissure [4] ), sellar floor and sphenoid
body (always crossing obliquely) (5), contra-
lateral jugum sphenoidale or ethmoid (6), and
orbital roof and apex (7). Force transmission
results from impact over a mastoid process.
(See Table 4.)
RG  •  Volume 41  Number 3 Dreizin et al  781

Conclusion 16. Diaz RC, Cervenka B, Brodie HA. Treatment of tempo-

ral bone fractures. J Neurol Surg B Skull Base 2016;77
The skull base is anatomically and function- (5):419–429.
ally complex, and fractures result in multifari- 17. Dahiya R, Keller JD, Litofsky NS, Bankey PE, Bonassar
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is based on the synergy between CT findings considerations. J Trauma 1999;47(6):1079–1083.
and results of physical examination, laboratory 18. Little SC, Kesser BW. Radiographic classification of temporal
testing, and neurosensory evaluation. To render bone fractures: clinical predictability using a new system. Arch
Otolaryngol Head Neck Surg 2006;132(12):1300–1304.
useful recommendations, radiologists should have 19. Alvi A, Bereliani A. Acute intracranial complications of
a realistic understanding of the often-comple- temporal bone trauma. Otolaryngol Head Neck Surg
mentary role of CT in guiding the management 1998;119(6):609–613.
20. Feldman JS, Farnoosh S, Kellman RM, Tatum SA 3rd.
pathway. Skull base trauma: clinical considerations in evaluation and
diagnosis and review of management techniques and surgical
Disclosures of Conflicts of Interest.—O.S. Activities related to approaches. Semin Plast Surg 2017;31(4):177–188.
the present article: disclosed no relevant relationships. Activities 21. Brodie HA, Thompson TC. Management of compli-
not related to the present article: consultant for Boston Imaging cations from 820 temporal bone fractures. Am J Otol
and Core Lab; speaker for Bayer; royalties from Gakken Medi- 1997;18(2):188–197.
cal Shujunsha and Medical Sciences International. Other activ- 22. Baltas I, Tsoulfa S, Sakellariou P, Vogas V, Fylaktakis M,
ities: disclosed no relevant relationships. D.G. Activities related Kondodimou A. Posttraumatic meningitis: bacteriology, hy-
to the present article: disclosed no relevant relationships. Activi- drocephalus, and outcome. Neurosurgery 1994;35(3):422–
ties not related to the present article: board member for Insightec; 426; discussion 426–427.
grants from Focused Ultrasound Foundation and Microven- 23. Archer JB, Sun H, Bonney PA, et al. Extensive traumatic
tion. Other activities: disclosed no relevant relationships. anterior skull base fractures with cerebrospinal fluid leak:
classification and repair techniques using combined vas-
cularized tissue flaps. J Neurosurg 2016;124(3):647–656.
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