Cerebrospinal fluid fistulas complicating missile wounds of the brain

The records of 101 casualties of the war in Vietnam have been analyzed, with particular attention to missile wounds of the brain complicated by a cerebrospinal fluid (CSF) fistula. Fifty four developed CSF drainage at the wound site, 30 presented with rhinorrhea, and 23 with otorrhea. Fifty of the 101 men developed infection, and incidence of 49.5%. The occurrence of a fistula in vertex wounds can usually be traced to failure to close the dura, or to achieve watertight closure of the dura primarily, or by graft. Approximately two-thirds of compound basilar fractures, complicated by rhinorrhea or otorrhea, are due to direct fractures of the anterior, middle, or posterior fossa. The remaining one third are due to elusive 'discrete' fractures of the base of the skull, occurring at a distance from the entry wound, and not in continuity with the fracture of the vault. While direct basilar fractures can readily be recognized, facilitating repair of the dura overlying the basilar fractures, 'discontinuous' fractures pose a challenging diagnostic problem. More commonly occurring in vertex wounds crossing the midline, discontinuous fractures producing rhinorrhea or otorrhea may be identified with the aid of tomograms of the base of the skull. Their early diagnosis may well prove to be a significant factor in the reduction of morbidity and mortality of missile wounds of the brain complicated by a CSF fistula.