Transverse clival fracture associated with bilateral petrous fractures extending through the occipital bone

Abstract

Transverse clival fractures, while rare, occur from significant trauma or lateral crushing of the head.1,2 Complications include injury to the intracranial vessels, cranial nerves, or brainstem.1,2 Patients can have high mortality. Clival fractures can be categorized into transverse, longitudinal, and oblique. Longitudinal and oblique fractures are associated with cranial nerve deficits. The morbidity and mortality rates are highest in longitudinal fractures. This 28-year-old woman presented after falling from a motor vehicle at a high speed. On initial examination she was intubated and had a right third cranial nerve (CN III) palsy. Corneal and cough reflexes were intact. She showed minimal extremity movement in response to noxious stimuli. CT imaging revealed frontotemporal contusions, a small occipital epidural hematoma, diffuse subarachnoid hemorrhage, and a fracture involving the bilateral occipital bones along the lambdoid suture and extending through both temporal bones, across the bilateral greater sphenoid wings, and transversely through the clivus; thus completely separating the cranial base from the cranial vault (Fig. 1). CT angiography revealed no vascular injury. High intracranial pressure was controlled with hyperosmolar therapy, external ventricular drainage, and pentobarbital coma and normalized over 10 days. She underwent tracheostomy and gastrostomy placement before discharge. At 3 months, she was speaking in 2-word sentences, following commands with mild right hemiparesis, and required assistance for ambulation. She had a right CN III palsy. The lower cranial nerves were intact. Her modified Rankin Scale score was 6. In our limited exposure to this massive an injury, it is rare not to have intracranial vascular injury or cranial nerve dysfunction. (DOI: 10.3171/2013.1.JNS121451)