POSTTRAVMATÝK BEYÝN OMURÝLÝK SIVISI FÝSTÜLLERÝNE YAKLAÞIM

Posttravmatik Beyin Omurilik Sývýsý Fistülleri (PBF) kafa travmalarýnýn morbidite ve mortaliteye neden olan ciddi komplikasyonlarýndan biridir. Sýklýkla rinore ve otore þeklinde görülürler ve travmadan sonraki ilk hafta içinde akut olarak baþlayabilecekleri gibi, nadir olarak aylar ve hatta yýllar sonra bile ortaya çýkabilmektedirler. Bu retrospektif çalýþmada, 2850 kafa travmasý olgusundan PBF tesbit edilen 48 (% 0.16) olgu sunuldu. Trafik kazasý 34 (% 70) olgu ile en sýk etyolojik neden idi. Onbeþ (%31.5) olguda temporal kemikte fraktür; bunlardan 8 inde ek olarak petroz kemikte fraktür, 31 (% 64.5) olguda paryetal kemikte fraktür; bunlardan 12 sinde ek olarak ethmoid kemikte fraktür, ayrýca 2 (% 4.1) olguda fronto-paryetal açýk çökme fraktürü ile birlikte ön fossada ve ethmoid kemikte fraktür tesbit edildi. Rinore 35 (% 73) olguda, otore 13 (% 27) olguda tesbit edildi. Travma sonrasý bir aydan geç baþvuran iki olgu (kronik) ve travmadan sonraki 48 saatten sonra baþvuran diðer iki olgu (subakut) hariç tüm olgular travmadan sonraki ilk 48 saat içinde (akut) hastanemize baþvurdular. Konservatif tedaviye cevap vermeyen 10 olguya bifrontal kranyotomi ile ön fossa eksplorasyonu þeklinde ekstradural ve/veya intradural cerrahi giriþim uygulandý. Olgulardan sadece birinde defekt primer olarak onarýlabildi, 8 olguda galea grefti ve bir olguda da serbest fasya lata grefti, ayrýca ek olarak bunlardan 8 inde fibrin doku yapýþtýrýcýsý, birinde siyanoakrilat kullanýldý. Tüm olgularda %100 iyileþme saðlandý, hiç bir olguda postoperatif fistül tesbit edilmedi. Menenjit kabul edilen 2 olgu dýþýnda hiçbir olguda menenjit geliþmedi. Tüm olgular ikili antibiyotik kombinasyonu ile proflaktik tedaviye alýndý. Posttravmatik beyin omurilik sývýsý fistüllerinde konservatif tedavinin ve proflaktik antibiyotik tedavisinin önemi, dirençli olgularýn cerrahi endikasyonlarý ve uygun cerrahi yaklaþým literatür gözden geçirilerek tartýþýldý.

EVALUATION OF POSTTRAUMATIC CEREBROSPINAL FLUID FISTULAS

Posttraumatic Cerebrospinal Fistulas (PBF) are serious complications of head trauma which may cause to morbidity and mortality. Usually, they present with rhinorrhea or otorrhea, and they occur acutely in the first week after the trauma, rarely months and years later. In this retrospective study, from 2850 patients suffered head trauma, 48 (% 0.16) of them had PBF. The most frequent etiology was traffic accident in 34 (% 70) cases. Fifteen (%31.5) of all cases had temporal bone fracture; 8 of them had also petrous bone fracture, 31 (% 64.5) cases had parietal bone fracture; 12 of them had also ethmoid bone fracture, 2 (% 4.1) cases had fronto-parietal open depression fracture, also with fracture in the anterior fossa and the ethmoid bone. Rhinorrhea was encountered in 35 (% 73) cases, and otorrhea in 13 (% 27) cases. All patients, except four of them, admitted in 48 hours after the trauma (acute). Ten patients were treated surgically who were unresponded to the conservative treatment. Bifrontal craniotomy with extradural and/or intradural anterior fossa eksploration was performed. Primer repair could be achieved only in one case, eight cases were treated with galea greft, one case with fascia lata greft. Additionally, 8 cases needed the use of fibrin glue, and one case siyanoacrilate. The success of surgical treatment was 100%, and no postoperative fistul formation was observed. Two cases had meningitis on admission. During hospital stay, any case in this series developed meningitis. All patients were treated with prophylactic two combinations antibiotic therapy. For the precise evaluation of PBF, the efficacy of the conservative treatment and prophylactic antibiotic therapy, surgical indications of resistant cases, and appropriate surgical treatment was discussed with literature review.