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Approaches to the Clivus: Approaches to No Man's Land
Cervical epidural haematoma can be traumatic or spontaneous; the last is associated with high blood pressure, vascular malformations, blood dyscrasias, use of medication, tumors, spinal taps They can be manifested in acute , or chronic 14 form, and are treated surgically in the majority of cases, although the conservative treatment also can be indicated to patients with incomplete and non-progressive deficits 6,9.
There is no report in the reviewed literature observing the association of cervical epidural haematomas and clival fractures.
In the admission the patient had a patent airway, with cervical spine imobilized, breathing on her own respiratory frequency 20 , hemodinamically stable blood pressure x60 mm Hg and cardiac frequency bpm , with active bleeding on her left inferior limb tibial fracture diagnosed latter on. She presented a flacid abdomen, voluntary rectal sphincter contraction and presence of fecal material to palpation, without signs of bleeding.
Chest and pelvis X-rays were normal. The cranial and cervical computed tomography showed transverse fracture of the clivus Fig 1 A and anterior cervical epidural haematoma Fig 1 B , which extended from the first to the third cervical vertebrae. Cervical MRI showed anterior cervical epidural haematoma Fig 2 A , extending from C1 to C3 and exerting some mass effect over the spinal cord.
Intracranial pressure was measured by a fiber-optic catheter, placed on the right ventricle, and the patient was monitored at the pediatric intensive care unit. The patient was also submitted to continuous monitorization of O2 extraction by a catheter placed in the right jugular vein. The patient was treated with dexamethasone and on mechanical ventilation under sedation for five days.
The sedation was suspended for brief periods daily and the patient examined again; no progression of deficits was confirmed. After five days, since the ICP and O2 extraction were within normal limits and CT scan showed no progression of haematoma, the sedation was suspended and the patient allowed to wake up. The first neurological examination after the sedation was suspended completely showed right hemiparesis, with evident increase of muscular strength GIII on arm and IV on the limb , and left pupil bigger than the right one.
CT scan was performed and showed spontaneous resolution of the haematoma Fig 3. The clivus is considered as the strongest bone of the skull base 4 ; it develops due to the fusion of the body of the sphenoid bone to the basilar portion of the occipital, and remains separated until ages higher than 12 years old by the spheno-occipital syncondrosis.
The spheno-occipital syncondrosis is the main growing center of the skull base after birth. Its growing allows the elongation of the medial portion of the skull base.
The arterial supply of the clivus is made cranially by the meningohypophyseal trunk and caudally by the posterior meningeal artery, anastomosed with the lateral clival artery Its deep localization, together with the anatomical center of the skull base protected by the facial structures, bone of the medial fosse and occipitium, makes the site infrequent to fractures 2,3.
The diagnosis is difficult by the imaging superposition in the x-ray and is usually described post-mortem 2,4. There are not large series and since this condition is probably underestimated, more complete information about the distribution of clival fractures on the pediatric population is not available. The mechanical forces responsible for the fracure are still under continuous controversy, but there had been described vertical 2 , lateral 2 and anterior-posterior forces 2,5,18 involved in these fractures.
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Radiologically, the clivus fractures can be classified as longitudinal, transverse and oblique 2, Petrous bone fractures, Horner syndrome and insipidus diabetes also were associated to the transverse and oblique clivus fracture 2,4. In the presented case the follow-up is too short three months to determine if there is any compromising of the skull base development. Cervical epidural haematoma is a very rare entity, and its etiology is divided in traumatic and spontaneous Its incidence after cervical trauma was estimated to be 1. The spontaneous cases can be secondary to pregnancy, blood dyscrasias, hypertension, vasculitis, vascular malformations or tumors 11,12, The traumatic ones can originate from vertebral fractures, obstetric traumas, postoperative bleeding, epidural anesthesia, penetrating trauma or even due to trauma with small impacts 6,8,9,13,14, It is described in 0.
The association of clival fracture and cervical epidural haematoma has not been described yet.
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The authors postulate that the haematoma may have its origin from the epidural venous plexus, oozing from the fracture itself or from a laceration of the arterial suply of the clivus. Clinically they manifest by myelo or radiculopaties, as an acute form more frequently 6,,15,16 , although they can have a chronic appearance They seem to have origin in venous blood from the epidural plexus 6,9,16 , although there is one description associated with arterial bleeding Cervical epidural haematomas are usually located on the dorsal region, although there is a case described with anterior localization, associared with fracture of C7-T1 joint, making this the second case of epidural cervical haematoma localized at the ventral region 9.
The treatment still remains controversial. If we consider that there is only one case described in the literature, it becomes evident the absence of protocol or guidelines to treat such cases. Crabbe et al. Other authors 8,,16 defend surgical intervention by laminectomy at the levels that correspond to the haematoma as mandatory treatment.
Approaches to the Clivus
Lefranc et al. In the presented case, the patient was submitted to clinical treatment with the use of dexamethasone since there was only a slight medullar compression. Clinical follow-up with adequate monitorization and daily neurological check up, with the aid of radiological control was assured.
The outcome was favorable. Occlusion of the basilar artery within a fracture of the clivus.