Complete ophthalmoplegia associated with clival fracture following trauma: Case report and clinicoanatomical correlation

Abstract

Fractures of clivus occur following high energy trauma and are rare. There are a few reports of associated vascular and brainstem injury in literature. We report a patient with transverse clivus fracture and complete ophthalmoplegia and bilateral multiple cranial nerve palsies. A young boy was admitted in altered sensorium following RTA. Initial imaging revealed diffuse pneumocephalus, subarachnoid hemorrhage and diffuse cerebral edema. He was treated conservatively. Clinical review after improvement in sensorium showed that he had visual loss in left eye, bilateral ptosis, complete ophthalmoplegia in horizontal as well as vertical gaze, bilateral trigeminal paresis, right facial weakness and dysarthria. There was right CSF otorrhea. A spiral CT scan revealed transverse clivus fracture extending into bilateral middle cranial base. The fracture line was involving facial canal and mastoid on the right side. An MRI brain demonstrated periaqueductal infarcts and multiple cortical infarcts. He was managed conservatively. In the presence of clinical suspicion of skull base injuries, a spiral CT scan and MRI brain and MR angiography are essential for accurate assessment of bony and neurological involvement. The diagnosis of clivus fracture should prompt the clinician to look for associated brainstem or basilar artery injury.

Keywords

Clivus fracture - post-traumatic ophthalmoplegia - post-traumatic cranial nerve palsy - midbrain injury - post-traumatic cortical infarcts

• References

• 1 Anthony DC, Atwater SK, Rozear MP, Burger PC. Occlusion of the basilar artery within a fracture of the clivus. J Neurosurg 66 1987; 929-931
• 2 Bonilha L, Fernandes YB, Joăo Paulo, Mattos de Vasconcelos, Adriano Wilson, Borges Abraăo, Borges G. Bilateralinternuclear ophthalmoplegia and clivus fracture following head injury- Case report. Arq.Neuro-Psiquiatr. 60 2002; 636-638
• 3 Corradino G, Wolf AL, Mirvis S, Joslyn J. Fractures of the clivus: classification and clinical features. Neurosurgery 27 1990; 592-596
• 4 Russell WR, Schiller F. Crushing injuries to the skull: clinical and experimental observations. J Neurosurg Psychiat 12 1949; 52-60
• 5 Paterakis KN, Karantanas AH, Hadjigeorgiou GM, Anagnostopoulos V, Karavelis A. Retroclival epidural hematoma secondary to a longitudinal clivus fracture. Clinical Neurology and Neurosurgery 108 2005; 67-72
• 6 Suliman HM, Merx HL, Wesseling P. et al Retroclival extradural hematoma is a magnetic resonance imaging diagnosis. J Neurotrauma 18 2001; 1289-1293
• 7 Khan N, Zumstein B. Transverse clivus fracture: Case presentation and significance of clinico-anatomic correlations. Surg Neurol 54 2000; 171-177
• 8 Sharma BS, Mahajan RK, Bhatia S, Khosla VK. Collet-Sicard syndrome after closed head injury. Clinical Neurology and Neurosurgery 96 1994; 197-198