TRAUMATIC OCCLUSION OF THE BASILAR ARTERY WITHIN A CLIVUS FRACTURE.

Abstract

Complex head injury is becoming a more frequent problem in clinical practice. In the case reported herein, radiographic studies were of particular value in disclosing the nature of the injury. The clinical picture suggested the possibility of a surgically correctable lesion. The radiographic findings, however, not only contraindicated operation, but permitted an exact anatomic diagnosis of a highly unusual condition. Clinical Summary S. L., a 59-year-old man, was struck on the head by a large beam. He was brought to the University Hospital within thirty minutes of the accident, unconscious, and with severe head and face injuries. A large ecchymotic, swollen area was present above the left eye. His nose was bleeding profusely, and the pharynx and both ears were filled with blood. The blood pressure was labile, the systolic varying between 140 and 110 mm. Hg and the diastolic between 80 and 70 mm. Hg. Respiration was rapid, deep, and regular, but labored. No response was elicited by painful stimulation or visual threat. Doll's-head eye movements (vestibulo-ocular reflex) were absent. Anisocoria was noted with the right pupil slightly larger than the left. Both pupils responded to light. Muscle stretch reflexes were present with bilateral extensor plantar responses. The muscular tonus was increased in the upper extremities. A suspected basal skull fracture could not be identified on initial skull films, although the sphenoid sinuses were fluid-filled . The cerebrospinal fluid had a 2 per cent hematocrit. Supportive care was given, but the patient failed to show any sign of recovery during the following days. There was some variation in eye movements. Acutely the eyes were fixed in the physiologic position. On the evening of admittance, random movements appeared in the right eye as the left continued to be fixed. Shortly thereafter, similar movements were seen in the left eye, but these remained random and disconjugate. No doll's-eye movements were present and the eyes remained fixed in the physiologic position. The right pupil remained larger than the left and both reacted directly and consensually to light. Electroencephalography on the sixth day showed a waking record with evidence of Severe dysrhythmia suggestive of brain stem and left cortical dysfunction. There was no electroencephalographic response to auditory or sensory stimulation. Light stimulation was not studied. The peculiarities this electroencephalographic finding have been discussed elsewhere (2). It was felt that the clinical picture was suggestive of a severe brain-stem lesion at the level of the pons, but, because expanding bilateral hematomas could not be ruled out clinically (4), a right carotid angiogram was obtained on the thirteenth day. The patient's neurologic and respiratory condition worsened following this examination, and he died in respiratory and cardiac collapse, fourteen days after his injury.