RESUMEN
Retroclival epidural hematomas (REDHs) are rare and almost exclusively found in the pediatric age group. Frequently, the etiology is related to accidental trauma, though other mechanisms have been observed, including coagulopathy, non-accidental trauma, and pituitary apoplexy. A 76-year-old man was admitted to our emergency department after a loss of consciousness. He presented with a Glasgow Coma Scale of 13(E3V4M6). He complained of headache accompanied by nausea and vomiting. A computer tomography (CT) revealed a hemorrhage along the clivus and dens. Magnetic resonance imaging (MRI) demonstrated the retroclival hematoma in epidural space. At discharge headache resolved without medical or operative intervention. REDHs are likely underdiagnosed in adults and magnetic resonance imaging is superior for identifying these lesions. Atlanto-occipital dislocation should be considered in all cases of REDH. Most cases exhibit a benign clinical course with conservative management, surgical management is dictated based on the presence of hydrocephalus, brainstem compression, and occipitocervical instability.
Asunto(s)
Accidentes por Caídas , Fosa Craneal Posterior/diagnóstico por imagen , Hematoma Epidural Craneal/diagnóstico por imagen , Hematoma Epidural Craneal/etiología , Anciano , Tratamiento Conservador/métodos , Fosa Craneal Posterior/lesiones , Estudios de Seguimiento , Hematoma Epidural Craneal/terapia , Humanos , MasculinoRESUMEN
We describe non-operative management a rare traumatic clival fracture extending through the bilateral occipital condyles. Clinical History: A 26-year-old female who was involved in a high-speed motor vehicle crash presented to an outside facility with difficulty speaking. Subsequent CT of the cervical spine demonstrated a fracture of the clivus with extension through the bilateral occipital condyles. She was then transferred to our hospital for further management where complete trauma survey noted multiple other injuries including traumatic subarachnoid hemorrhage, spinal epidural hematoma, bilateral pneumothoraces, liver laceration, bilateral upper extremity injuries, and lumbosacral fractures. Additional spinal imaging was negative for any associated vascular or spinal cord injury. Given her young age, there was a strong interest to preserve craniocervical motion and the decision was made to treat her with non-operatively with halo placement. After 18 weeks of rigid fixation, follow up imaging demonstrated completely healed fractures and at twenty-one weeks post fixation she demonstrated preserved motion of the craniocervical junction. This is a review of the literature and case report regarding this rare entity and its management.
Asunto(s)
Accidentes de Tránsito , Fosa Craneal Posterior/diagnóstico por imagen , Fosa Craneal Posterior/lesiones , Fijadores Externos , Hueso Occipital/diagnóstico por imagen , Fracturas Craneales/diagnóstico por imagen , Adulto , Vértebras Cervicales/diagnóstico por imagen , Femenino , Humanos , Movimiento (Física) , Fracturas Craneales/etiología , Fracturas Craneales/terapiaRESUMEN
A review of the literature revealed that basilar artery (BA) entrapment is a very rare (17 cases published) and severe pathological condition, which often leads to death. We report the case of a 72-year-old man who presented with a longitudinal clivus fracture associated with a basilar artery entrapment. This entrapment was responsible for a basilar artery dissection, which led to an ischemic stroke in the pons. The patient was managed with medical treatment, mainly to avoid a progression towards an ischemic stroke. It consisted of heparin therapy followed by antiplatelet therapy, which finally resulted in a successful outcome. In BA entrapment most of the patients who had a favorable outcome received antithrombotic therapy. This suggests that antithrombotic therapy might be useful in the first line treatment of post-traumatic BA entrapment.
Asunto(s)
Fosa Craneal Posterior/lesiones , Fosa Craneal Posterior/cirugía , Procedimientos Neuroquirúrgicos/métodos , Fractura Craneal Basilar/cirugía , Insuficiencia Vertebrobasilar/cirugía , Anciano , Angiografía de Substracción Digital , Anticoagulantes/uso terapéutico , Isquemia Encefálica/etiología , Fosa Craneal Posterior/diagnóstico por imagen , Heparina/uso terapéutico , Humanos , Imagen por Resonancia Magnética , Masculino , Inhibidores de Agregación Plaquetaria/uso terapéutico , Puente/patología , Fractura Craneal Basilar/complicaciones , Fractura Craneal Basilar/diagnóstico por imagen , Accidente Cerebrovascular/etiología , Resultado del Tratamiento , Insuficiencia Vertebrobasilar/diagnóstico por imagen , Insuficiencia Vertebrobasilar/etiologíaRESUMEN
Although vascular complications after head trauma is well recognized, basilar artery entrapment within the longitudinal clivus fracture is rare. A 69-year-old man presented with progressive disturbance of consciousness and right hemiplegia after trauma. Computed tomography scan showed a right-sided acute subdural hematoma and multiple skull fractures, including a longitudinal clivus fracture. Magnetic resonance imaging revealed basilar artery occlusion and a small infarction at the ventral part of the pons. On the assumption of acute arterial occlusion caused by thrombus, endovascular thrombectomy was attempted, but resulted in perforation. After the procedure, basilar artery entrapment within the longitudinal clivus fracture turned out to be the cause of the occlusion. The present case suggests that basilar artery entrapment within the longitudinal clivus fracture is a possible cause of neurological deficits after trauma. In this subset, endovascular intervention without a correct diagnosis of this phenomenon is high risk.
Asunto(s)
Arteria Basilar , Trastornos Cerebrovasculares/etiología , Trastornos Cerebrovasculares/cirugía , Fosa Craneal Posterior/lesiones , Procedimientos Endovasculares , Fracturas Craneales/complicaciones , Anciano , Trastornos Cerebrovasculares/diagnóstico , Humanos , Masculino , Fracturas Craneales/diagnósticoRESUMEN
Traumatic clival fractures in the pediatric population are associated with high mortality rates. In our previously reported series, a subset of clival fractures were associated with traumatic diastasis of the surrounding clival synchondroses. Herein, we describe a pediatric case of an isolated traumatic diastasis of the clival synchondroses without clival fracture with significant injury to neurovascular structures. To our knowledge this is the first report to describe this entity. Careful radiological attention should be made towards the clival synchondroses in crushing head injuries to best tailor screening for cerebrovascular injury even in the absence of clival fractures.
Asunto(s)
Fosa Craneal Posterior/lesiones , Diástasis Ósea , Fracturas Craneales/complicaciones , Traumatismos del Sistema Nervioso , Lesiones Traumáticas del Encéfalo/rehabilitación , Preescolar , Fosa Craneal Posterior/diagnóstico por imagen , Escala de Coma de Glasgow , Humanos , Angiografía por Resonancia Magnética , Masculino , Estudios Retrospectivos , Fracturas Craneales/diagnóstico por imagen , Fracturas Craneales/fisiopatología , Traumatismos del Sistema Nervioso/diagnóstico por imagenRESUMEN
Although rarely reported in the literature, serious occipital and condylar fractures have been diagnosed more often with the widespread use of computed cranial tomography in traumas. In this paper, a 16-year-old female with a left occipital fracture extending from the left occipital condyle anterior of the hypoglossal canal to the inferior part of the clivus is presented. The fracture which had caused a neurological deficit was cured with conservative treatment. For delayed hypoglossal nerve paralysis due to swelling within the canal, methylprednisolone was started, and a complete cure was attained in about 10 days. Traumatic damage of bony structures of the condyle and clivus at the junction of many vital nerves, vessels, and ligaments may lead to traumatic deficit and death.
Asunto(s)
Fosa Craneal Posterior/lesiones , Hueso Occipital/lesiones , Traumatismos del Sistema Nervioso/complicaciones , Adolescente , Antiinflamatorios/uso terapéutico , Angiografía por Tomografía Computarizada , Femenino , Humanos , Traumatismos del Nervio Hipogloso/etiología , Metilprednisolona/uso terapéutico , Hueso Occipital/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Traumatismos del Sistema Nervioso/diagnóstico por imagenRESUMEN
Clival fracture is a rare and serious injury, which mostly results in the death of the victim before reaching the hospital. The entity is hardly diagnosed in the early phase because of high mortality rates and deficiencies in completion of radiological imaging. The incidence of diagnoses increased year by year after the usage of computed tomography gained widespread availability. In this article, we aimed to present radiological and clinical characteristics of a 5-year-old patient brought to the emergency department after a motor vehicle accident. The most current recommendations with regard to the management of clival fracture of a pediatric patient are also discussed.
Asunto(s)
Fosa Craneal Posterior/lesiones , Fracturas Craneales/diagnóstico , Accidentes de Tránsito , Angiografía/métodos , Preescolar , Femenino , Paro Cardíaco/etiología , Humanos , Fracturas Craneales/complicaciones , Tomografía Computarizada por Rayos X/métodosRESUMEN
BACKGROUND: Infratentorial subdural hygromas causing secondary occlusive hydrocephalus are extremely rare in children. Only a handful of cases have been reported in the literature. METHODS: We present a case of a 6-month-old infant with an occipital fracture and slow enlargement of a posterior fossa subdural hygroma that culminated in obstructive hydrocephalus. We give a review of the literature on post-traumatic posterior fossa hygroma with secondary occlusive hydrocephalus and discuss its pathogenesis and the mechanism of its later resolution, as well as the available treatment options. RESULTS: A temporary external ventricular drain led to acute relief of the hydrocephalus and subsequent complete resolution of the subdural hygroma. CONCLUSION: Temporary external ventricular drain placement led to complete resolution of the subdural hygroma and hydrocephalus. We recommend close clinical follow-up, and imaging if indicated, for as long as 4 weeks after trauma with occipital skull fractures.
Asunto(s)
Fosa Craneal Posterior/cirugía , Hidrocefalia/cirugía , Fracturas Craneales/cirugía , Efusión Subdural/cirugía , Fosa Craneal Posterior/diagnóstico por imagen , Fosa Craneal Posterior/lesiones , Humanos , Hidrocefalia/diagnóstico por imagen , Hidrocefalia/etiología , Lactante , Masculino , Fracturas Craneales/complicaciones , Fracturas Craneales/diagnóstico por imagen , Efusión Subdural/diagnóstico por imagen , Efusión Subdural/etiologíaRESUMEN
Cases of cerebrospinal fluid (CSF) rhinorrhea due to clival fracture are rare. We present a case of bacterial meningitis with CSF rhinorrhea after a clival fracture. Heavily T2-weighted images showed a bone flap in the thinned clivus and fluid collection in the sphenoid sinus. CSF rhinorrhea developed at 1 month after mild trauma. The fracture may have been caused by the trauma and/or by the pressure gradient between the intracranial CSF space and the sphenoid sinus. A detailed history to identify trauma and an examination to detect bone defects in the skull base are necessary when patients present with bacterial meningitis and persistent rhinorrhea.
Asunto(s)
Rinorrea de Líquido Cefalorraquídeo/etiología , Fosa Craneal Posterior/lesiones , Meningitis Bacterianas/etiología , Fracturas Craneales/complicaciones , Adulto , Humanos , MasculinoAsunto(s)
Fosa Craneal Posterior/lesiones , Fosa Craneal Posterior/patología , Boca/lesiones , Heridas Penetrantes/patología , Adulto , Fosa Craneal Posterior/diagnóstico por imagen , Fosa Craneal Posterior/cirugía , Escala de Coma de Glasgow , Humanos , Imagen por Resonancia Magnética , Masculino , Tomógrafos Computarizados por Rayos X , Heridas Penetrantes/diagnóstico por imagen , Heridas Penetrantes/cirugíaRESUMEN
BACKGROUND: Penetrating brain injury (PBI) can be caused by several objects ranging from knives to chopsticks. However, an assault with long and electric screwdriver is a peculiar accident and is relatively rare. Because of its rarity, the treatments of such injury are complex and nonstandardized. CASE PRESENTATION: We presented a case of a 54-year-old female who was stabbed with a screwdriver in her head and accompanied by loss of consciousness for 1 h. Computer tomography (CT) demonstrated that the screwdriver passed through the right zygomatic bone to posterior cranial fossa. Early foreign body removal and hematoma evacuation were performed and the patient had a good postoperative recovery. CONCLUSIONS: In this study, we discussed the clinical presentation and successful management of such a unique injury caused by a screwdriver. Our goal is to demonstrate certain general management principles which can improve patient outcomes.
Asunto(s)
Hemorragia Encefálica Traumática/cirugía , Traumatismos Penetrantes de la Cabeza/cirugía , Hemorragia Subaracnoidea Traumática/cirugía , Hemorragia Encefálica Traumática/diagnóstico por imagen , Fosa Craneal Posterior/lesiones , Femenino , Traumatismos Penetrantes de la Cabeza/diagnóstico por imagen , Humanos , Persona de Mediana Edad , Hemorragia Subaracnoidea Traumática/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Cigoma/lesionesRESUMEN
We report a rare case of entrapment of the basilar artery into the sphenoid bone caused by a longitudinal fracture of the clivus. Using high resolution three-dimensional flat panel angiography, we show preservation of the basilar artery perforators in spite of severe stenosis of the entrapped segment of the basilar artery. There were no obvious signs and symptoms of posterior fossa stroke clinically or radiographically as far as could be assessed under given clinical circumstances.
Asunto(s)
Arteria Basilar/diagnóstico por imagen , Infartos del Tronco Encefálico/diagnóstico por imagen , Puente/irrigación sanguínea , Fracturas Craneales/diagnóstico por imagen , Insuficiencia Vertebrobasilar/diagnóstico por imagen , Infartos del Tronco Encefálico/etiología , Fosa Craneal Posterior/diagnóstico por imagen , Fosa Craneal Posterior/lesiones , Humanos , Masculino , Fracturas Craneales/complicaciones , Insuficiencia Vertebrobasilar/etiología , Adulto JovenRESUMEN
BACKGROUND: Traumatic clival fractures occur with less than 0.6% frequency and can be associated with significant neurovascular injuries. The most serious of these injuries is to the basilar artery in which the artery is dissected or is fully occluded, resulting in infarction of the brainstem and cerebellum. Among early reports of these injuries, postmortem autopsy showed entrapment, or incarceration, of the basilar artery at the clival fracture site. A literature search revealed 11 cases of entrapment of the basilar artery within a clival fracture. CASE DESCRIPTION: This report describes a 59-year-old man after a motor vehicle crash with computed tomography showing a basilar artery herniation through a sphenoid sinus fracture. The patient subsequently developed brainstem and cerebellar infarcts. CONCLUSIONS: Basilar artery incarceration and herniation through the sphenoid sinus is rare. Such an injury portends a poor prognosis. We discuss the relevant clinical imaging and review the literature.
Asunto(s)
Arteria Basilar/lesiones , Fosa Craneal Posterior/lesiones , Fractura Craneal Basilar/cirugía , Seno Esfenoidal/cirugía , Accidentes de Tránsito , Autopsia , Arteria Basilar/diagnóstico por imagen , Angiografía por Tomografía Computarizada , Imagen de Difusión por Resonancia Magnética , Escala de Coma de Glasgow , Humanos , Imagenología Tridimensional , Masculino , Persona de Mediana Edad , Fractura Craneal Basilar/diagnóstico por imagen , Seno Esfenoidal/diagnóstico por imagenRESUMEN
We report a rare case of entrapment of the basilar artery into the sphenoid bone caused by a longitudinal fracture of the clivus. Using high resolution three-dimensional flat panel angiography, we show preservation of the basilar artery perforators in spite of severe stenosis of the entrapped segment of the basilar artery. There were no obvious signs and symptoms of posterior fossa stroke clinically or radiographically as far as could be assessed under given clinical circumstances.
Asunto(s)
Fosa Craneal Posterior/lesiones , Fractura Craneal Basilar/complicaciones , Insuficiencia Vertebrobasilar/etiología , Accidentes de Tránsito , Fosa Craneal Posterior/irrigación sanguínea , Humanos , Puente/irrigación sanguínea , Grado de Desobstrucción Vascular , Adulto JovenRESUMEN
BACKGROUND: Though traumatic posterior fossa epidural hematoma (PFEDH) is rare, the associated rates of morbidity and mortality are higher than those of supratentorial epidural hematoma (SEDH). Signs and symptoms may be silent and slow, but rapid deterioration may set in, resulting in death. With the more frequent use of computed tomography (CT), early diagnosis can be achieved in patients with cranial fractures who have suffered traumatic injury to the posterior fossa. However, some hematomas appear insignificant or are absent on initial tomography scans, and can only be detected by serial CT scans. These are called delayed epidural hematomas (EDHs). The association of EDHs in the supratentorial-infratentorial compartments with linear fracture and delayed EDH (DEDH) was presently investigated. METHODS: A total of 212 patients with SEDH and 22 with PFEDH diagnosed and treated in Göztepe Training and Research Hospital Neurosurgery Clinic between 1995 and 2005 were included. Of the PFEDH patients, 21 underwent surgery, and 1 was followed with conservative treatment. In this group, 4 patients underwent surgery for delayed posterior fossa epidural hematoma (DPFEDH). RESULTS: Mean age of patients with PFEDH was 12 years, and that of the patients with SEDH was 18 years. Classification made according to localization on cranial CT, in order of increasing frequency, revealed of EDHs that were parietal (27%), temporal (16%), and located in the posterior fossa regions (approximately 8%). Fracture line was detected on direct radiographs in 48% of SEDHs and 68% of PFEDHs. Incidence of DPFEDH in the infratentorial compartment was statistically significantly higher than incidence in the supratentorial compartment (p=0.007). Review of the entire EDH series revealed that the likelihood of DEDH development in the infratentorial compartment was 10.27 times higher in patients with linear fractures than in patients with supratentorial fractures (p<0.05). CONCLUSION: DPFEDH, combined with clinical deterioration, can be fatal. Accurate diagnosis and selection of surgery modality can be lifesaving. The high risk of EDH development in patients with a fracture line in the posterior fossa on direct radiographs should be kept in mind. These patients should be kept under close observation, and serial CT scans should be conducted when necessary.
Asunto(s)
Fosa Craneal Posterior/lesiones , Traumatismos Craneocerebrales/complicaciones , Hematoma Epidural Craneal/diagnóstico , Adolescente , Adulto , Niño , Fosa Craneal Posterior/diagnóstico por imagen , Traumatismos Craneocerebrales/diagnóstico por imagen , Femenino , Escala de Coma de Glasgow , Hematoma Epidural Craneal/diagnóstico por imagen , Hematoma Epidural Craneal/etiología , Hematoma Epidural Craneal/cirugía , Humanos , Masculino , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , Turquía , Adulto JovenRESUMEN
Clival screw and plate fixation technique is an alternative or supplement to the occipitocervical instrumentation. However, no report has clarified the applied anatomy of clivus in patients with atlas assimilation (C1A), especially for clival screw fixation. Therefore, we measured the parameters of clival lengths, widths, putative screw lengths, clival-cervical angel and foramen magnum diameters on CT images in a cohort of 81 C1A patients and patients without C1A. The clivus showed a rectangular shape in 96.3% (78/81) of C1A patients, and a normal-like triangle shape in 3.7% (3/81) of C1A patients. The intracranial clival length decreased 13% (37 mm) in C1A patients, the extracranial clival length 14.8% (24.1 mm), the clival-cervical angle 6.2% (122.3°) and the superior screw length 11.3% (14.1 mm), the sagittal diameter of foramen magnum 16% (28.0 mm), respectively. There was no significant difference in the widest or narrowest clival width, or the middle screw length, or the transverse diameter of foramen magnum between groups. The inferior clivus was feasible for an average 9.7-mm-length screw placement in C1A patients, while not in patients without C1A. The present study characterizes clivus of C1A patients with an unnormal-like rectangular shape, and confirmes a screw placement at the inferior clivus.
Asunto(s)
Tornillos Óseos , Fracturas Craneales , Tomografía Computarizada por Rayos X , Adulto , Fosa Craneal Posterior/diagnóstico por imagen , Fosa Craneal Posterior/lesiones , Fosa Craneal Posterior/cirugía , Femenino , Foramen Magno/diagnóstico por imagen , Foramen Magno/lesiones , Foramen Magno/cirugía , Humanos , Masculino , Persona de Mediana Edad , Fracturas Craneales/diagnóstico por imagen , Fracturas Craneales/cirugíaRESUMEN
BACKGROUND: Vertebrobasilar artery entrapment resulting from a clivus fracture is rare. The entrapped lesions are not radiographically depicted precisely because they are only identified by autopsy or completely occluded. In addition, no changes in the features have been revealed clearly because radiologic examinations were performed only in the acute stage. CASE DESCRIPTION: We report a case of traumatic entrapment of the vertebral artery depicted precisely by a three-dimensional angiographic study in the subacute stage, presenting the serial changes in the morphologic features and a review of the published cases. CONCLUSION: It is necessary to manage vertebrobasilar artery entrapment cautiously because it is suggested that the entrapped lesion is accompanied by arterial dissection.
Asunto(s)
Accidentes por Caídas , Hematoma Intracraneal Subdural/diagnóstico por imagen , Fracturas Craneales/diagnóstico por imagen , Hemorragia Subaracnoidea Traumática/diagnóstico por imagen , Arteria Vertebral/diagnóstico por imagen , Insuficiencia Vertebrobasilar/diagnóstico por imagen , Angiografía de Substracción Digital , Angiografía Cerebral , Angiografía por Tomografía Computarizada , Fosa Craneal Posterior/diagnóstico por imagen , Fosa Craneal Posterior/lesiones , Imagen de Difusión por Resonancia Magnética , Dilatación Patológica/diagnóstico por imagen , Dilatación Patológica/etiología , Hueso Frontal/diagnóstico por imagen , Hueso Frontal/lesiones , Hematoma Intracraneal Subdural/complicaciones , Hematoma Intracraneal Subdural/cirugía , Humanos , Imagenología Tridimensional , Masculino , Persona de Mediana Edad , Fracturas Craneales/complicaciones , Hueso Esfenoides/diagnóstico por imagen , Hueso Esfenoides/lesiones , Hemorragia Subaracnoidea Traumática/complicaciones , Tomografía Computarizada por Rayos X , Insuficiencia Vertebrobasilar/etiologíaRESUMEN
OBJECTIVES: Routine transnasal rhinological procedures are widely practiced and are considered as safe, in general. Skull base lesions occur in less than 1% of procedures and typically involve the anterior or middle cranial fossa, while clivus lesions have not been well documented. Here we present a series of three patients with iatrogenic transclival lesions after routine transnasal rhinological procedures. PATIENTS AND METHODS: Three patients with penetrating clivus injuries after routine transnasal rhinological procedures were identified. All patients had undergone transnasal rhinological surgery at other hospitals and two of them were referred for emergency treatment. Patients were managed within an interdisciplinary context. RESULTS: There were two women and one man. Mean age at surgery was 35 years. All operations had been performed under general anaesthesia. In only one instance, perforation of the clivus had been noticed during surgery by the ENT physician, while it went unnoticed in the other two patients. In one patient, no intracranial injury occurred secondary to the clivus fracture, while two patients had extensive brainstem lesions. The first patient survived without deficits, but one patient succumbed to the brainstem injury and the other remained with severe deficits. Risk factors including anatomical variants or distorted morphology were present in all patients. CONCLUSION: Transnasal rhinological procedures can result in penetrating clivus injuries, which may not be noticed during surgery, but which can result in permanent morbidity or mortality. These lesions are obviously very rare and their true incidence remains unknown.
Asunto(s)
Base del Cráneo/lesiones , Cirugía Endoscópica Transanal/efectos adversos , Adolescente , Adulto , Anciano , Fosa Craneal Posterior/lesiones , Femenino , Humanos , Enfermedad Iatrogénica , MasculinoRESUMEN
Unlike basilar skull fractures, penetrating traumatic injuries to the clivus are uncommon. We present two novel and interesting cases of traumatic crossbow arrow injury and penetrating screwdriver injury to the clivus. A review of the literature describing methods to repair these injuries was performed. A careful, systematic approach is required when working up and treating these injuries, as airway preservation is critical. An adaptation to the previously described "gasket-seal" method for skull base repair was utilized to repair the traumatic cerebrospinal fluid (CSF) fistulas. This repair technique is unique in that it is tailored to a much smaller defect than typical post-surgical defects. Two patients are presented, one with a post-traumatic CSF fistula after penetrating crossbow injury to the clivus and one with a penetrating screwdriver injury to the clivus. The patients were treated successfully with transnasal endoscopic repair with fascia lata graft and a nasoseptal flap, a novel adaptation to the previously described "gasket-seal" technique of skull base repair.