Complete ophthalmoplegia associated with clival fracture following trauma: Case report and clinicoanatomical correlation

Abstract

Fractures of clivus occur following high energy trauma and are rare. There are a few reports of associated vascular and brainstem injury in literature. We report a patient with transverse clivus fracture and complete ophthalmoplegia and bilateral multiple cranial nerve palsies. A young boy was admitted in altered sensorium following RTA. Initial imaging revealed diffuse pneumocephalus, subarachnoid hemorrhage and diffuse cerebral edema. He was treated conservatively. Clinical review after improvement in sensorium showed that he had visual loss in left eye, bilateral ptosis, complete ophthalmoplegia in horizontal as well as vertical gaze, bilateral trigeminal paresis, right facial weakness and dysarthria. There was right CSF otorrhea. A spiral CT scan revealed transverse clivus fracture extending into bilateral middle cranial base. The fracture line was involving facial canal and mastoid on the right side. An MRI brain demonstrated periaqueductal infarcts and multiple cortical infarcts. He was managed conservatively. In the presence of clinical suspicion of skull base injuries, a spiral CT scan and MRI brain and MR angiography are essential for accurate assessment of bony and neurological involvement. The diagnosis of clivus fracture should prompt the clinician to look for associated brainstem or basilar artery injury.

Keywords

• Clivus fracture
• post-traumatic ophthalmoplegia
• post-traumatic cranial nerve palsy
• midbrain injury
• post-traumatic cortical infarcts