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Injury to the ophthalmic and maxillary divisions of the trigeminal nerve may be the result of either a basal fracture across the middle cranial fossa or a direct extracranial injury to the branches of the nerves Numbness and paresthesias of the skin supplied by the nerve(s) or a neuralgia can be troublesome sequelae of these injuries The facial nerve may be involved in one of two ways In the rst type of injury, associated with transverse fractures through the petrous bone, there is an immediate facial palsy, probably due to contusion or transection of the nerve Surgical anastomosis has sometimes been successful in this circumstance The second, more common type, is associated with longitudinal fractures of the petrous bone, the facial palsy then often being delayed for several days a sequence that may be misinterpreted as progression of the intracranial traumatic lesion This latter type is usually transitory, and its mechanism is not known Injury to the eighth cranial nerve due to petrous fractures results in a loss of hearing or in postural vertigo and nystagmus coming on immediately after the trauma Deafness due to nerve injury must be distinguished from the high-tone hearing loss due to cochlear injury and from deafness caused by bleeding into the

If the skin over a skull fracture is lacerated and the underlying meninges are torn, or if the fracture passes through the inner wall of a paranasal sinus, bacteria may enter the cranial cavity, with resulting meningitis or abscess formation Also, CSF that leaks into the sinus present as a watery discharge from the nose (CSF rhinorrhea) The nasal discharge can be identi ed as CSF by testing it for glucose with diabetic test tape (mucus has no glucose) or by the presence of uorescein or iodinated water-soluble dye that is injected into the lumbar subarachnoid space and then absorbed by pledgets placed in the nasal cavity Most cases of acute CSF rhinorrhea heal by themselves If the condition is persistent or is complicated by an episode of meningitis, repair of the torn dura mater is indicated The prophylactic use of antibiotics to prevent meningitis from a nasal CSF leak is currently not favored, but many neurosurgeons continue this practice, particularly in children (see page 599) A collection of air in the cranial cavity (aerocele) is a common occurrence following skull fracture or following an extended neurosurgical procedure It is usually found (by CT scan) in the epidural or subdural space over the cerebral convexities or between the hemispheres and serves only to warn of a potential route for the entry of bacteria into the cranium Small collections of air are usually absorbed without incident, but a large collection of air may act as a mass and cause clinical deterioration after injury (tension pneumocranium; Fig 35-3) Inhalation of 100% oxygen has a salutary effect, but needle aspiration of the air is required if it is causing clinical signs (Fig 35-3)

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Figure 35-3 CT of postoperative tension pneumocranium (aerocele) that caused progressive drowsiness and required removal by aspiration The air is apparent as a very low density collection that compresses the frontal lobes

Depressed ( derby hat ) fractures are of signi cance only if the underlying dura is lacerated or the brain is compressed by indentation of bone They should then be surgically repaired, preferably within the rst 24 to 48 h

Mechanisms of Concussion Much has been written about the mechanisms of concussion and coma in closed, or blunt, head injury Certain facts concerning these conditions stand out: (1) Concussion, meaning a reversible traumatic paralysis of nervous function, is always immediate (not delayed even by seconds) (2) The effects of concussion on brain function may last for a variable time (seconds, minutes, hours, or longer) To set arbitrary limits on the duration of loss of consciousness ie, to consider a brief loss as indicative of concussion and a prolonged loss as indicative of contusion or other traumatic cerebral lesion, as proposed in some older medical writings is illogical and unsound physiologically As pointed out by Symonds, any such difference is quantitative, not qualitative Admittedly, in the more prolonged states of coma, there is a greater chance of nding hemorrhage and contusion, which undoubtedly contribute to the persistence of coma and the likelihood of irreversible change (3) The optimal condition for the production of concussion, demonstrated originally by Denny-Brown and Russell, is a sudden change in the momentum of the head; ie, either movement is imparted to the stationary head by a blow or movement of the head is arrested by a hard, unyielding surface These two types of blunt (nonpenetrating) head injury are called accelerative and decelerative, respectively The mechanism of concussive cerebral paralysis has been interpreted in various ways throughout medical history in light of the state of scienti c knowledge at a particular period of time The

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