Document Type: Case Report

Authors

1 Resident of Neurosurgery, Department of Neurosurgery, Sina Hospital, Emam Ave. Tehran University of Medical Sciences (TUMS), Tehran, Iran

2 Department of Neurosurgery, Sina Hospital, Emam Ave. Tehran University of Medical Sciences, Tehran, Iran

Abstract

Sheno-occipital diastasis happens more frequently in children and is accompanied with neural and vascular injuries leading to a high rate of mortality. We present a rare type of clival fracture in a 21 years old man who could survive without any deficit even though the fracture extended widely from left Asterion to the right orbit accompanied by widespread damage of the skull base air sinuses in 3D CT scan. To the best knowledge of the authors, neither this type of fracture, nor the clinical presentation, has been reported in relevant literature.

Keywords

Introduction

We present a 20-year-old boy with pneumocephalus after direct blow to the left occiput and review the literature briefly. Clivus is an uncommon site for skull base fracture. Population based studies show that clivus fracture occurs most commonly in pedestrians involved in traffic accidents.  The extent and type of fracture depends on the trajectory and magnitude of the trauma [1-8]. Longitudinal and oblique fractures are suggested as the more devastating types in different studies [2]. There was an oblique clivus fracture (CVF) with sphenooccipital dehiscence but the patient had no neurological deficit. We would like to suggest this type of skull base fracture to be included in the classification skull base fractures.

 

Case report

A 20-year-old man was brought to our level 1 trauma center with severe headache after a direct blow to the head on the left side of the occiput. He was conscious, oriented and had a good memory of the moment of the injury. We found a superficial laceration of the scalp on the left occiput and no rhinorrhea or ottrrhagia. The neurological examination was completely normal, and the patient had fluent, clear speech. A head CT scan revealed diffuse pneumocephalous with the pattern of the gyri. Paranasal sinuses were filled with cerebro-spinal fluid (Figure 1). There was a linear skull base fracture, extending from the left petrous bone, crossing the sphenooccipital synchondrosis and extending to the roof of orbit on the right side (Figure 1). The fracture line traversed the sphenoid sinus, the right anterior clinoid process and the right sphenoid wing also. No insult to the internal carotid artery (ICA) or vertebral and basilar arteries were detected in CTV.  Patient was admitted to the intensive care unit and treated with complete bed rest and continuous high concentration oxygen mask. The pneumocephalus decreased remarkably and patient was transferred to the ward after three days.  He was discharged home after seven days and was asymptomatic when last visited after 3 months. Appropriate informed consent is taken from the patient and is present in the file.

Fig. 1 White arrow in the middle showing the horizontal and vertical fracture lines and dehiscence of the clivus with axial subluxation to the left (a). Fracture line is demarcated using white arrow starting from the base of the right mastoid bone coming to the lateral and mid clivus (b). Arrows showing fractured left anterior clinoid process in figures (c). Extension of the fracture line to the left orbital plate and sphenoid wing (a, b). 3D reconstruction of the skull base region shows whole the fracture line shaded to highlight the CVF all along the skull base (d).

 

 

Discussion

Clivus is a thick part of the occipital bone that forms a gradual sloping process at the anterior most portion of the basilar occipital bone at its junction with the sphenoid bone via ‘spheno-occipital synchondrosis’ and the petrosal part of the temporal bone on each side [1]. The cartilaginous connection between the clivus and the body of sphenoid is ossified in the adolescence up to the age of 15 and skull is more prone for clivus dehiscence in childhood [5,6]. Our case was a 20-year-old man.

Fracture of the clivus is a rare event and is seen only in 0.21% - 0.56% of traumatic head injuries. The trauma is usually a blunt one with compressive nature. The compressive pattern of the trajectory of the trauma or vector of the force is of main importance in development of CVF in most of the reported cases [4]. In our patient the fracture occurred due to a direct blunt trauma to the left Asterion. The vector of the force created an oblique line of fracture that extended from the left petrous bone to the sphenooccipital synchondrosis, then to the right anterior clinoid process and crossed to the roof of the right orbit (Figures 1A, B, C, D). The sphenoid and the ethmoid sinuses were also smashed by the vector of force passing through the skull base in this case.

 Corradino et al., [2] 1990, classified clival fractures to longitudinal, horizontal and oblique shapes. Wrinckler-Schwarts A et al., [8] subdivided the fracture types according to the extent of bonny damage. Neither of the authors’ classifications nor the existing literature can describe the CVFs in a convincing way for each case. That is one of the main reasons to present this case of ours with diastatic/displaced CVF as a very rare event and as a sample to be included in further multicentral studies for classification of CVFs.

The reported morbidity and mortality rate have been between 24% and 31% in different studies [3,4]. One of the theories to explain the death at the scene of traumatic brain injuries (TBI) after clivus fracture is that, the basilar artery may be crushed by the separated bone fragments [1]. Direct or indirect trauma to the cranial nerves can explain the neurological deficits usually occurring in such cases. In our case, a unilateral blunt trauma which was not severe enough to cause brain parenchymal damage, lead into this rare type of sphenooccipital dehiscence without any morbidity. We highlighted the main take away message of this case which can be important for neuro-trauma surgeons and radiologists.

In conclusion, a rare case of CVF is presented to be enrolled in the classification list of the clival fractures.

 

Declarations:

The ethics committee of Sina Hospital approved resenting the data of the file of the patient in this report.

No grant, financial support or funding for any of the authors.

Appropriate informed consent is taken from the patient and is present in the file.

All the authors contributed in preparation of the manuscript equally.

Conflict of Interest: The authors declare that they have no competing interests. 

Table 1. Showing the list of other cases of skull base fracture with sufficient information to be compared to our case.

 

Age/

gender

Cranial fracture

Neurologic deficit, additional findings

Prognosis

Khan and Zumstein

19/M

Fracture in petrous bone

 Deficit in cranial nerves 3, 6 and 7

GCS: 15

Arizavakan et al.

18/M

Left anterior cranial fossa base

Fracture in roof of right orbit

Ophthalmoplegia and bilateral multiple cranial nerve palsies

Diffuse pneumocephalus with extension into lateral

Subarachnoid hemorrhage

Evers et al.

43/M

Left occipital fracture

Fracture of the atlas, anterior arch lower end

Retrograde amnesia

Mild motor deficit

Home

Okten et al.

19/M

Fracture in petrous bone

GCS: 3-4

Death

Ochalski et al.

32/F

Petro-occipital fracture

Occipitomastoid fracture

SDH

GCS: 5, home

 

16/M

SAH

ICA dissection

Rehabilitation

 

15/F

Sphenooccipital fracture

Petrooccipital fracture

Occipitomastoidal fracture

EDH, SDH, contusion,

Bilat MCA & ACA infarcts

Brain death

 

6/M

Occipital hematoma and fracture

SAH, EDH

CN VII palsy, Bilat CN VIII palsy

Home

 

16/M

SAH

ICA dissection

GCS: 7

Rehabilitasyon

Menkü et al.

25 M

Transverse

Right CN VI palsy

Improvement

 

17 M

Transverse

Left CN III palsy

Bilateral CN VI palsy

Death, 7 days

 

45 F

Transverse

CN II palsy

Bilateral CN VI palsy

Left CN VII palsy

Left Blindness

 

54 M

transverse

Left VI

Improvement

 

68 M

Longitudinal

Rt III VII

Death

 

18 M

Longitudinal

Lt VII

Lt hemiparesis

 

32 M

longitudinal

Lt III, bilat VI, Lt VII

Lt VII

 

48 F

Longitudinal

Lt VII

Death

 

38 F

Longitudinal

Right III, VI, VII

Death

Sanders and Vander

16/F

transverse

CN V, VI, VII paralysis

Horner syndrome

GCS: 15

 

26

transverse

CN VI,VII paralysis, Horner syndrome

GCS: 15

 

9/F

transverse

CN III, IV, V, VI,VII paralysis

Horner syndrome

ICA stenosis

GCS: 15

Kapila and Chakeres

21M

Transvers cliv fracture

Bilateral CN VI paralysis

CSF otorrhea

CCF

GCS: 15

Corradino et al. Joslyn et al.

 32 y 

Transvers clivus fracture

CN III, IV, V paralysis

Bilateral CN VI, VII paralysis

Death

Akar, Ö et al.

38/M

Small sxial fracture lowest part of clivus

no deficit

GCS: 15, home

Our case

20 M

Fracture from Rt. Asterion to Let orbit with clival dehescenc

No deficit

GCS: 15, home

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