Presentation
High-energy head trauma. The patient fell off a scaffold. GCS 7 on the stage. Intubated.
Patient Data
Brain CT shows subarachnoid hemorrhage, prevalent in the basal cisterns. Axial CT images with bone window show bi-frontal vertical skull vault fracture in continuity with a basal skull fracture involving anterior fossa (fracture of planum ethmoidalis on both sides), middle fossa (anterior and posterior clinoid processes and pituitary fossa) and posterior fossa (where a vertical clival fracture extending to the right occipital condyle is seen). AngioCT in the arterial phase shows no basilar artery filling (just behind the vertical fracture of the clivus)
FLAIR images show signal abnormality in multiple vascular territories of posterior circulation with corresponding restricted diffusion at the DWI/ADC images, consisting with acute ischemia. Axial and coronal T2 images show "entrapped" basilar artery within the longitudinal clival fracture
Case Discussion
This is a case of high-energy head trauma with occlusion of the basilar artery, "entrapped" within a longitudinal fracture of the clivus. In cases of head trauma with longitudinal fracture of the clivus associated with cisternal subarachnoid hemorrhage, think about a vascular trauma of the basilar artery.
Fractures of the clivus can be classified as longitudinal, transverse, or oblique, based on their orientation. High impact injury of the cranium is involved in all fracture types. Clival fractures are associated with a high mortality rate of 67-80% due to the high incidence of associated vascular injury 1. The high mortality rate is due to the development of infarction of the posterior circulation (brainstem and cerebellum) secondary to vertebrobasilar artery injury, either from arterial occlusion or dissection. Entrapment of the vertebrobasilar arteries is a rare but reported complication of longitudinal clival fractures, but also of high-energy head trauma without a clival fracture but with minor bone defect 2.
Unable to process the form. Check for errors and try again.