Skull Base Fractures and Cerebrovascular Injuries More Than a Casual Acquaintance: A Case Report

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Critical Care Medicine





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Introduction: Rarely injured due to its position, the clivus is the deepest bone of the skull base. Clivus fractures are often associated with neurovascular injuries due to the significant blunt force necessary to cause injury. Injury to the clivus carries a high mortality rate, between 24-31% (1). CT scan is the preferred modality in diagnosing clivus fractures. When found, screening CT-angiography (CTA) of the neck and, if abnormal, a subsequent four-vessel cerebrovascular angiogram be performed due to the association with blunt cerebral vascular injury (BCVI). Here we describe a case of a 26M who sustained bilateral carotid and bilateral vertebral vessel tears with extravasation leading to arteriovenous fistula (AVF) formation following a 50 foot fall down a canyon. Methods: A 26-year-old male fell 50 feet down a canyon while hiking. The patient was a GCS 15 presenting with polytrauma complaining of neck and head pain. CT scan revealed multisystem trauma. Due to obscuration of the basal cisterns from SAH, a clivus fracture, and a CTA with aneurysmal change of the right vertebral artery, a 4-vessel cerebrovascular angiogram was performed. This demonstrated bilateral traumatic carotid (CA) and bilateral vertebral artery (VA) vascular tears with extravasation at skull base at the same level and an associated dural tear consistent with a stretch injury. The patient was monitored clinically and with short interval repeat imaging. The repeat 4-vessel angiogram revealed two AVF on the right and was managed with IR embolization. Results: This case demonstrates several important screening and management implications for traumatic CA and VA vascular tears with extravasation at skull the base. Firstly, patients who present with clival fractures and high ISS should be screened for BCVI and possibly despite a negative/equivalent CTA be considered for formal 4-vessel cerebrovascular angiography. Secondly traumatic CA and VA tears with extravasation without signs of complete transection due to BCVI can be managed non-operatively. It is strongly recommended that short interval follow up with 4-vessel cerebrovascular angiography be performed. Any intervention for fistula/aneurysm at the skull base is best performed endovascularly by a neurologic specialist either Neuro trained IR or neurosurgery.





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