- Email: [email protected]
A rare clival and sellar fracture with pneumatocephalus
Auris Nasus Larynx 29 (2002) 195– 198 www.elsevier.com/locate/anl
Case report
A rare clival and sellar fracture with pneumatocephalus Fre´de´ric Portier *, Didier Salvan, Olivier Duruisseau, Philippe Herman, Patrice Tran Ba Huy Clinique d’ORL et de Chirurgie Cer6ico-Faciale, Hoˆpital Lariboisie`re, 2 rue Ambroise Pare´, 75010, Paris, France Received 7 May 2001; received in revised form 13 August 2001; accepted 21 September 2001
Abstract We present a case of clival and sellar complex fracture produced by an indirect mechanism. This previously healthy patient had an occipital trauma followed by epistaxis. CT showed a clival and sellar fracture with pneumatocephalus. The probable fracture mechanism was contre-coup injury, linked to cerebral shock-wave transmission. This type of fracture is generally observed in the anterior part of the skull base, in a low resistance area. Severe osteoporosis probably accounted for the unusual fracture site in this patient. A mechanism of direct clival transmission is discussed, together with the usual complications of sphenoid injuries. © 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Head trauma; Epistaxis; Sphenoid
1. Introduction Skull-base fractures generally occur after violent anterior, lateral or posterior head trauma. Shock-wave transmission can occur directly through the skull-base bones (sphenoid greater wings, petrous bone), or indirectly through the cerebral parenchyma (contre-coup mechanism [1]). The usual mechanism of sphenoid injury is shock-wave transmission through the greater wings. A contre-coup, frequently involved in anterior skull base fracture after occipital trauma, seemed to be the mechanism of sphenoid fracture in this patient with severe osteoporosis.
2. Case report A 68-year-old woman suffered occipital cranial trauma, without loss of consciousness, after falling over * Corresponding author. Present address: Service d’ORL et Chirurgie Cervico-Faciale, Hoˆpital de Biceˆtre, 78, rue du Ge´ne´ral Leclerc, 94275 Le Kremlin-Biceˆtre, France. Tel.: +33-1-4521-3128; fax: + 331-4521-3773. E-mail address: [email protected] (F. Portier).
backwards from her full height. She was admitted to the emergency department with a voluminous occipital hematoma, non pulsatile headaches and epistaxis. A few minutes after admission she vomited a little blood. She said she had fallen backwards at home and that she had only suffered occipital trauma. No damage to the nasal pyramid was found. Nasal examination evidenced moderate hemorrhage but no evidence of wounding. She complained of headache and sleepiness, although neurological examination was normal. CT revealed suprasellar air linked to a sphenoidal fracture involving the clival and sellar areas, and a sphenoidal hemosinus (Figs. 1 and 2). No CSF leakage occurred. A new CT-analysis revealed marked sphenoidal bone hypodensity compatible with severe osteoporosis (Fig. 3). She was discharged 3 days later, with no headache or impairment of consciousness. After discharge, the patient did not present repeated epistaxis. Control CT 1 month later showed the disappearance of the pneumatocephalus and sphenoidal hemosinus, and no evidence of carotid artery aneurysm. Pituitary function (hormone assay) and diuresis were normal, ruling out diabetes insipidus.
0385-8146/02/$ - see front matter © 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 8 5 - 8 1 4 6 ( 0 1 ) 0 0 1 3 9 - 0
196
F. Portier et al. / Auris Nasus Larynx 29 (2002) 195–198
3. Discussion Transsphenoid basilar skull fractures generally occur along reproducible lines of weakness, including a coronal plane through the anterior sphenoid body and pterygoid plates, a coronal plane through the posterior sphenoid body and clivus, and the sphenopetrosal synchondrosis [2]. The usual mechanism is direct injury linked to osseous transmission of the shock wave:
blows to the side of the head in the squamous temporal region may run across the floor of the middle cranial fossa through the greater wing of the sphenoid in the transverse cranial axis. In this case the fracture is generally oriented in a saggital plane, seated on the spheno-occipital suture, without pneumatocephalus [2]. The literature contains no descriptions of sphenoid bone injuries after occipital trauma. Possible fracture mechanisms in our patient are: (i) direct bony transmis-
Fig. 1. Axial CT showing pneumatocephalus (arrows) and sphenoidal hemosinus (arrowhead).
Fig. 2. Sagittal reconstruction showing clival and sellar fractures (arrows) and pneumatocephalus (arrowhead).
F. Portier et al. / Auris Nasus Larynx 29 (2002) 195–198
197
Fig. 3. Axial CT showing severe skull base osteoporosis (stars) involving the clivus (Fig. A, arrow) and the sella turcica (Fig. B, arrows).
sion through sphenooccipital synchondrosis; (ii) indirect contre-coup injury of the sphenoid bone, linked to cerebral shock-wave transmission. In the hypothesis of a direct sphenooccipital transmission, one would expect that the whole clivus would be seriously injured in case of such osteoporosis (Fig. 3), and that sella turcica would not be involved. For this reason, diagnosis of indirect sphenoidal fracture by contre-coup mechanism was retained by our radiologists. Contre-coup fractures of the skull base are described as rare in the literature. The relationship between the site of head impact and the type of fracture is well described [3]. The main mechanism is occipital trauma, fracturing the low-resistance floor of the anterior skull base [1], because of an effect of summation of osseous and cerebral oscillations which cause a pressure gradient inside the skull [3]. Situated in an area which is not affected by the oscillation, the sella turcica should be protected against trauma. In our patient the uncommon location of the injury could be explained by severe osteoporosis. The three main complications of sphenoidal injury are aneurysms of the internal carotid artery [4], CSF fistula [5] and diabetes insipidus [6]. In the rare cases of internal carotid aneurysm, recurrent epistaxis is the most frequent symptom, and may or may not be associated with a sphenoidal sinus syndrome. In the literature, life-threatening epistaxis can occur up to 9 weeks after the injury. For this reason, carotid exploration is essential after sphenoid injury with or without initial epistaxis. In patients without initial life-threatening epistaxis, angiography or contrast-enhanced CT should be deferred for 2– 3 weeks [4]. If this first evaluation
reveals normal findings, repeated epistaxis should prompt a second evaluation. Current treatment involves occlusion of the main artery through the use of endovascular techniques (detachable balloons and coils). CSF fistulas are revealed by CSF rhinorrhea, but meningitis may be the first manifestation. Muscle packing of the sphenoidal sinus seems to be the most effective treatment [5]. Diabetes insipidus is a rare but well-known complications of cranial trauma characterized by polyuria and polydipsia. Patients may compensate for polyuria and nocturia by excessive fluid intake. The diagnosis is based on a comparison of urine and plasma osmolality in the patient with that of normal subjects. Neurogenic diabetes insipidus may respond to nasal desmopressin administration [6].
4. Conclusion Skull base contre-coup fracture is a rare injury mainly occurring after occipital trauma. The fracture usually occurs in the anterior part of the skull base, because of low osseous resistance. However, other skull base areas seem to be possibly involved in case of bone abnormalities such as osteoporosis. Epistaxis occurring after occipital trauma requires investigation. It is important to diagnose sphenoidal injury, given the risk of rare but potentially life-threatening complications (internal carotid artery aneurysm and diabetes insipidus).
198
F. Portier et al. / Auris Nasus Larynx 29 (2002) 195–198
References [1] Hein PM, Schulz E. Contrecoup fractures of the anterior cranial fossa as a consequence of blunt force caused by a fall. Acta Neurochir (Wien) 1990;105(1 –2):24–9. [2] West OC, Mirvis SE, Shanmuganathan K. Transsphenoid basilar skull fracture: CT patterns. Radiology 1993;188(2):329 –38. [3] Ruan JS, Khalil T, King AI. Dynamic response of the human head to impact by three-dimensional finite element analysis. J Biomech Eng 1994;116(1):44 –50.
[4] Uzan M, Cantasdemir M, Seckin MS, Hanci M, Kocer N, Sarioglu AC, Islak C. Traumatic intracranial carotid tree aneurysms. Neurosurgery 1998;43(6):1314 – 22. [5] Loew F, Pertuiset B, Chaumier EE, Jaksche H. Traumatic, spontaneous and postoperative CSF rhinorrhea. Adv Tech Stand Neurosurg 1984;11:169 – 207. [6] Kern KB, Meislin HW. Diabetes insipidus: occurrence after minor head trauma. J Trauma 1984;24(1):69 – 72 January.
Case report
A rare clival and sellar fracture with pneumatocephalus Fre´de´ric Portier *, Didier Salvan, Olivier Duruisseau, Philippe Herman, Patrice Tran Ba Huy Clinique d’ORL et de Chirurgie Cer6ico-Faciale, Hoˆpital Lariboisie`re, 2 rue Ambroise Pare´, 75010, Paris, France Received 7 May 2001; received in revised form 13 August 2001; accepted 21 September 2001
Abstract We present a case of clival and sellar complex fracture produced by an indirect mechanism. This previously healthy patient had an occipital trauma followed by epistaxis. CT showed a clival and sellar fracture with pneumatocephalus. The probable fracture mechanism was contre-coup injury, linked to cerebral shock-wave transmission. This type of fracture is generally observed in the anterior part of the skull base, in a low resistance area. Severe osteoporosis probably accounted for the unusual fracture site in this patient. A mechanism of direct clival transmission is discussed, together with the usual complications of sphenoid injuries. © 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Head trauma; Epistaxis; Sphenoid
1. Introduction Skull-base fractures generally occur after violent anterior, lateral or posterior head trauma. Shock-wave transmission can occur directly through the skull-base bones (sphenoid greater wings, petrous bone), or indirectly through the cerebral parenchyma (contre-coup mechanism [1]). The usual mechanism of sphenoid injury is shock-wave transmission through the greater wings. A contre-coup, frequently involved in anterior skull base fracture after occipital trauma, seemed to be the mechanism of sphenoid fracture in this patient with severe osteoporosis.
2. Case report A 68-year-old woman suffered occipital cranial trauma, without loss of consciousness, after falling over * Corresponding author. Present address: Service d’ORL et Chirurgie Cervico-Faciale, Hoˆpital de Biceˆtre, 78, rue du Ge´ne´ral Leclerc, 94275 Le Kremlin-Biceˆtre, France. Tel.: +33-1-4521-3128; fax: + 331-4521-3773. E-mail address: [email protected] (F. Portier).
backwards from her full height. She was admitted to the emergency department with a voluminous occipital hematoma, non pulsatile headaches and epistaxis. A few minutes after admission she vomited a little blood. She said she had fallen backwards at home and that she had only suffered occipital trauma. No damage to the nasal pyramid was found. Nasal examination evidenced moderate hemorrhage but no evidence of wounding. She complained of headache and sleepiness, although neurological examination was normal. CT revealed suprasellar air linked to a sphenoidal fracture involving the clival and sellar areas, and a sphenoidal hemosinus (Figs. 1 and 2). No CSF leakage occurred. A new CT-analysis revealed marked sphenoidal bone hypodensity compatible with severe osteoporosis (Fig. 3). She was discharged 3 days later, with no headache or impairment of consciousness. After discharge, the patient did not present repeated epistaxis. Control CT 1 month later showed the disappearance of the pneumatocephalus and sphenoidal hemosinus, and no evidence of carotid artery aneurysm. Pituitary function (hormone assay) and diuresis were normal, ruling out diabetes insipidus.
0385-8146/02/$ - see front matter © 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 8 5 - 8 1 4 6 ( 0 1 ) 0 0 1 3 9 - 0
196
F. Portier et al. / Auris Nasus Larynx 29 (2002) 195–198
3. Discussion Transsphenoid basilar skull fractures generally occur along reproducible lines of weakness, including a coronal plane through the anterior sphenoid body and pterygoid plates, a coronal plane through the posterior sphenoid body and clivus, and the sphenopetrosal synchondrosis [2]. The usual mechanism is direct injury linked to osseous transmission of the shock wave:
blows to the side of the head in the squamous temporal region may run across the floor of the middle cranial fossa through the greater wing of the sphenoid in the transverse cranial axis. In this case the fracture is generally oriented in a saggital plane, seated on the spheno-occipital suture, without pneumatocephalus [2]. The literature contains no descriptions of sphenoid bone injuries after occipital trauma. Possible fracture mechanisms in our patient are: (i) direct bony transmis-
Fig. 1. Axial CT showing pneumatocephalus (arrows) and sphenoidal hemosinus (arrowhead).
Fig. 2. Sagittal reconstruction showing clival and sellar fractures (arrows) and pneumatocephalus (arrowhead).
F. Portier et al. / Auris Nasus Larynx 29 (2002) 195–198
197
Fig. 3. Axial CT showing severe skull base osteoporosis (stars) involving the clivus (Fig. A, arrow) and the sella turcica (Fig. B, arrows).
sion through sphenooccipital synchondrosis; (ii) indirect contre-coup injury of the sphenoid bone, linked to cerebral shock-wave transmission. In the hypothesis of a direct sphenooccipital transmission, one would expect that the whole clivus would be seriously injured in case of such osteoporosis (Fig. 3), and that sella turcica would not be involved. For this reason, diagnosis of indirect sphenoidal fracture by contre-coup mechanism was retained by our radiologists. Contre-coup fractures of the skull base are described as rare in the literature. The relationship between the site of head impact and the type of fracture is well described [3]. The main mechanism is occipital trauma, fracturing the low-resistance floor of the anterior skull base [1], because of an effect of summation of osseous and cerebral oscillations which cause a pressure gradient inside the skull [3]. Situated in an area which is not affected by the oscillation, the sella turcica should be protected against trauma. In our patient the uncommon location of the injury could be explained by severe osteoporosis. The three main complications of sphenoidal injury are aneurysms of the internal carotid artery [4], CSF fistula [5] and diabetes insipidus [6]. In the rare cases of internal carotid aneurysm, recurrent epistaxis is the most frequent symptom, and may or may not be associated with a sphenoidal sinus syndrome. In the literature, life-threatening epistaxis can occur up to 9 weeks after the injury. For this reason, carotid exploration is essential after sphenoid injury with or without initial epistaxis. In patients without initial life-threatening epistaxis, angiography or contrast-enhanced CT should be deferred for 2– 3 weeks [4]. If this first evaluation
reveals normal findings, repeated epistaxis should prompt a second evaluation. Current treatment involves occlusion of the main artery through the use of endovascular techniques (detachable balloons and coils). CSF fistulas are revealed by CSF rhinorrhea, but meningitis may be the first manifestation. Muscle packing of the sphenoidal sinus seems to be the most effective treatment [5]. Diabetes insipidus is a rare but well-known complications of cranial trauma characterized by polyuria and polydipsia. Patients may compensate for polyuria and nocturia by excessive fluid intake. The diagnosis is based on a comparison of urine and plasma osmolality in the patient with that of normal subjects. Neurogenic diabetes insipidus may respond to nasal desmopressin administration [6].
4. Conclusion Skull base contre-coup fracture is a rare injury mainly occurring after occipital trauma. The fracture usually occurs in the anterior part of the skull base, because of low osseous resistance. However, other skull base areas seem to be possibly involved in case of bone abnormalities such as osteoporosis. Epistaxis occurring after occipital trauma requires investigation. It is important to diagnose sphenoidal injury, given the risk of rare but potentially life-threatening complications (internal carotid artery aneurysm and diabetes insipidus).
198
F. Portier et al. / Auris Nasus Larynx 29 (2002) 195–198
References [1] Hein PM, Schulz E. Contrecoup fractures of the anterior cranial fossa as a consequence of blunt force caused by a fall. Acta Neurochir (Wien) 1990;105(1 –2):24–9. [2] West OC, Mirvis SE, Shanmuganathan K. Transsphenoid basilar skull fracture: CT patterns. Radiology 1993;188(2):329 –38. [3] Ruan JS, Khalil T, King AI. Dynamic response of the human head to impact by three-dimensional finite element analysis. J Biomech Eng 1994;116(1):44 –50.
[4] Uzan M, Cantasdemir M, Seckin MS, Hanci M, Kocer N, Sarioglu AC, Islak C. Traumatic intracranial carotid tree aneurysms. Neurosurgery 1998;43(6):1314 – 22. [5] Loew F, Pertuiset B, Chaumier EE, Jaksche H. Traumatic, spontaneous and postoperative CSF rhinorrhea. Adv Tech Stand Neurosurg 1984;11:169 – 207. [6] Kern KB, Meislin HW. Diabetes insipidus: occurrence after minor head trauma. J Trauma 1984;24(1):69 – 72 January.