Management of cocaine-induced midline lesion (CIMDL) extended to skull base: a case report and systematic review.

Abstract

Purpose: Cocaine-induced midline destructive lesions (CIMDL) represent a rare but severe consequence of intranasal cocaine abuse, occasionally progressing to skull base involvement with life-threatening complications. The aim of this manuscript is to describe an exceptional case of CIMDL with clival destruction and brainstem exposure, and to review current management strategies based on a systematic literature review.

Methods: We report a unique case of a 39-year-old woman with CIMDL extending to the clivus, resulting in encephalocele with basilar artery and brainstem exposure. Surgical repair was performed using a temporo-parietal fascia flap (TPFF), followed by a secondary repair with a free omental flap. A systematic review of the literature was conducted according to PRISMA guidelines, including all relevant cases of skull base involvement in CIMDL.

Results: Of 337 studies screened, 12 met inclusion criteria. Among these, surgical approaches varied widely, with a subset of patients managed conservatively, and no clearly preferred surgical strategy emerging. Outcomes highlight the feasibility and limitations of each approach and the importance of individualized surgical planning.

Conclusion: This report emphasizes the importance of early multidisciplinary intervention and provides practical insights for the management of potentially fatal cases in selected CIMDL with skull base destruction. Moreover, it exposes the need for individualized surgical planning and reconsideration of conventional abstinence-based timing criteria in selected high-risk cases. This review also highlights the challenges in the development of standard management guidelines due to the rarity nevertheless heterogeneous scenarios of these clinical entities.