Injury Extra (2006) 37, 416—418

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CASE REPORT

Isolated fourth ventricular haematoma associatedwith traumatic atlanto-occipital dislocation

Mehmet Tatli a,*, Aslan Guzel a, Kazim Yigitkanli b, Hakan Seckin b

aDepartment of Neurosurgery, Faculty of Medicine, University of Dicle, 21280 Diyarbakir, TurkeybClinic of Neurosurgery, Diskapi Research and Education Hospital, Ankara, Turkey

Accepted 18 April 2006

Introduction

Traumatic atlanto-occipital dislocation causes up to31% of motor vehicle fatalities.1 In emergency con-ditions, there is a high percentage of underdiagnosiswith the initial conventional radiographic evalua-tion.2,6 Injuries of the facial region and chest andintracranial haematoma are associated withatlanto-occipital dislocation.2,4 Infratentorialbleeding is rare, and in most instances, subarach-noid haematoma is diagnosed. This report describesa case of isolated fourth ventricular haematoma in acase of traumatic atlanto-occipital dislocation witha relatively long-term survival.

Case report

History

A 12-year-old boy was brought to the author’s hos-pital after a hit by a motor vehicle. From his history,we learnt that he was a pedestrian, and the accidentoccured 30 min befor admission. The patient wasintubated at the scene.

* Corresponding author. Tel.: +90 412 229 25 92;fax: +90 412 248 85 23.

E-mail address: mtatli@dicle.edu.tr (M. Tatli).

1572-3461/$ — see front matter # 2006 Elsevier Ltd. All rights resedoi:10.1016/j.injury.2006.04.127

Examination

He sustained a left parietal and right frontal scalplaceration. On neurological examination, he wascomatose with middilated pupils with slight reac-tion to light. He had shallow respiration. His Glas-gow coma scale was 3T. A full trauma assessmentwas performed, and no other injuries werededected. A plain cervical spine series and com-puted tomography (CT) scan of the head wereperformed. The lateral view of the cervical spinerevealed a retropharyngeal haematoma and ante-rior atlanto-occipital dislocation (Type 1),10

(Fig. 1). The dens-basion interval was measuredas 25 mm, and basion-posteriorinteraxial line wasmeasured as 21 mm. Powers ratio was calculated as2.6. The unenhanced CT scan revealed a fourthventricular haematoma (Fig. 2). The other CT find-ings were normal.

Carotid and vertebral arteries doppler ultraso-nography were unremarkable. Magnetic resonanceimaging (MRI) and an angiography were considereddue to the high incidence of vertebral arteryinjury. However, we could not perform becauseof the poor clinical condition of the patient andmechanical ventilation. The initial management ofthis injury consisted of immobilisation of the neckwith hard cervical collar. High-dose steroids werestarted, and mechanical ventilation was applied.

rved.

Traumatic atlanto-occipital dislocation 417

Figure 1 The lateral view of the cervical spine demon-strating a large retropharyngeal haematoma and anterioratlanto-occipital dislocation (Type 1).

His clinical course did not improve and any sign ofrecovery was not detected during follow-up per-iod. The patient died on the fifth day of hospita-lisation.

Figure 2 An unenhanced CT scan demonstrating an iso-lated fourth ventricular haematoma (arrow).

Discussion

The clinical presentation of traumatic atlanto-occi-pital dislocation ranges from death to normal neu-rological status. There are often associated findingsof facial, cranial or chest trauma.2,3 The localisationof traumatic facial or cranial lesions may give cluesof the trauma mechanism and may raise suspicion oftraumatic vertebral injury.2,5

Radiological evaluation starts with lateral cervi-cal spine radiographs. This is reported to be over-looked up to 50%.6,8 Prevertebral soft tissueswelling is the most frequent indirect finding. Mea-surements of the dental basion interval, basionaxial line, atlanto-occipital joint distance, atlanto-dental interval, or Powers ratio greater than 1 areusually diagnostic.9 CT scan of the occipitocervicaljunction may provide evidence of atlanto-occipitaldislocation by showing incongruity between occipi-tal condyles and the opposing atlantal articularmasses.3

CT of the head also may provide informationabout associated intracranial haematomas or injuryto the neural structures.1,7—9

The forces resulting in traumatic atlanto-occipi-tal dislocation is of high-energy acceleration/dec-celeration type that overcome the muscular andligamentous attachments of the craniocervicaljunction.2,9 The fatal outcome is usually causedby mechanical damage to upper brainstem or spinalcord. However, neurological sequel in survivors isattributed to spinal cord contusion or ischaemiafrom vascular injury.6 Vascular injury ranges fromvasospasm and dissection of the carotid and verteb-ral arteries to complete transection with extravasa-tion.2,6,8 Radiologically, these injuries werereported to present as subdural or epidural haema-tomas or subarachnoid haemorrhage.1,2,7—9 How-ever, isolated fourth ventricular haematomaassociated with traumatic atlanto-occipital disloca-tion have not been reported before. The blood in thefourth ventricle might be related to the headtrauma or could be a coincidental finding, but theCT scan of our patient showed only isolated fourthventricle haematoma and did not reveal any sign oftraumatic brain injury. Therefore, we suggest thatthe possibility of isolated fourth ventricle haema-toma caused by head trauma is very low in our case.An MRI and an arteriogram would certainly havehelped, but could not be performed. The patternof haematoma in our case suggests arteries of smallcaliber or venous origin and may be related to theatlanto-occipital dislocation.

It is not clear if the mass effect of the additionalhaematoma in the fourth ventricle added to theclinical condition of the patient. Unfortunately,

418 M. Tatli et al.

magnetic resonance imaging could not be obtained,and computed tomography is not sufficient todelineate the brain stem and spinal cord. Never-theless, an evident Type 1 dislocation (Powers ratiowas 2.6) and neurological status on admission, in ourpatient, suggest the primary injury in the vitalneural structures.

Conclusion

The extent of radiological findings in atlanto-occi-pital dislocation varies from subtle lateral cervicalspine findings to intracranial haematoma. Isolatedfourth intraventricular haematoma may be the onlyassociated radiological finding and may suggestinjury to the occipitocervical region in traumapatients.

References

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