Figure 4: Raccoon’s eyes (periorbital ecchymosis) and mastoid
ecchymosis (Battle’s sign)
Hemotympanum may also be a sign of basilar skull fracture. If otorrhea
is noted, a cerebrospinal fluid (CSF) leak can be detected by the presence of β-
2 Transferrin. Despite the risk of meningitis with basilar skull fractures (2 – 9%),
the routine use of prophylactic antibiotics is not recommended as increased use
tends to select out for resistant organisms [12-15].^ On the other hand, patients
with a basilar skull fracture and a CSF leak should be considered for
vaccination against Streptococcus pneumonia due to the increased risk of
pneumococcal-associated meningitis [16].
II. Evaluation and Management
The management after TBI relies on an understanding of the Monro-
Kellie doctrine and the avoidance of secondary brain injury. The Monro-Kellie
doctrine states that given that the cranium is a rigid, nonexpansile container,
the total volume of the intracranial contents must remain constant and any
increase in the volume of one component must be at the expense of the others,
assuming the intracranial volume remains constant (Figure 5). Despite the