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Images in Neurology |

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

Jorge García-García, MD; Miguel Villar-Garcia, MD; Lorenzo Abad, MD; Tomas Segura, MD, PhD
Arch Neurol. 2012;69(5):662. doi:10.1001/archneurol.2011.1155.
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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.

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Figure 1. Computed tomographic (CT) scans. A, Three-dimensional CT scan on admission demonstrates multiple craniofacial injuries. B, Initial bone-window CT scan showing a longitudinal fracture of the clivus (white arrow). C, Three-dimensional CT angiogram. The black arrow indicates entrapment of the midbasilar artery in the clivus fracture.

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Figure 2. Magnetic resonance imaging (MRI). A, Diffusion-weighted MRI demonstrates acute infarction in the left pons. B, Sagittal T2-weighted MRI. The white arrow shows herniation of the basilar artery into the clivus fracture. C, An MRI angiogram showing gradual tapering of the basilar artery and flow from the carotid system through posterior communicating arteries.

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