Brainstem Infarct Due to Traumatic Basilar Artery Entrapment Caused by Longitudinal Clival Fracture

A 37-year-old man had major craniofacial injuries after falling from a height of 4 m (Figure 1A). Neurological examination at the emergency department showed left severe hemiparesis and bilateral internuclear ophthalmoplegia with a Glasgow Coma Scale score of 15. The initial computed tomography (CT) head scan revealed an acute left frontal epidural hemorrhage and a longitudinal clivus fracture (Figure 1B). Three-dimensional CT angiogram reconstruction displayed the longitudinal fracture line in the clivus with the basilar artery trapped in it (Figure 1C). A subsequent cerebral magnetic resonance imaging angiogram demonstrated ischemic infarction in the central and right pons, entrapment of the basilar artery, and gradual tapering of this same artery with flow communication from the carotid to the basilar artery through posterior communicating arteries (Figure 2A and C). To avoid progressive thrombus formation and occlusion of the penetrating vessels, intravenous heparin was administered during 3 weeks without any complication. Serial brain CT scans disclosed no enlargement of the epidural hemorrhage. During the next 4 weeks, the patient's neurological condition improved, and he was discharged 35 days after admission. He showed mild hemiparesis with moderate disability requiring some help to walk. Heparin treatment was discontinued after 3 weeks and changed for aspirin.