Zone Approach to Skull Fractures and Associated Intracranial Complications

SUMMARY: In the United States, approximately 2.5 million emergency department visits occur per year following head trauma. Noncontrast CT is the initial imaging technique of choice given its wide availability, rapid acquisition time, and sensitivity for detecting skull fractures and intracranial hemorrhage. However, standardized, clinically relevant classification systems for skull injury stratification with CT are lacking. Such classification systems have greatly enhanced the diagnosis and management of midfacial fractures and could similarly impact the care of patients with cranial injuries. Our aim is to provide a classification system that encompasses injuries to the entirety of the cranium using a zone approach to skull fractures. We propose 4 zones of injury that are anatomically divided as follows: 1) occipitoparietal, 2) frontobasal, 3) lateral skull base, and 4) central skull base. For each zone, we will discuss its anatomic boundaries, fracture patterns, and commonly associated intracranial complications. We hope this systematic approach can better inform appropriate follow-up imaging and clinical management. Abbreviations CN: cranial nerve DVST: dural venous sinus thrombosis EDH: epidural hematoma LFD: lateral frontal diagonal NOE: naso-orbital-ethmoidal PT: posterior transverse SNHL: sensorineural hearing loss SSS: superior sagittal sinus