Atlanto-occipital dislocation with retroclival hematoma in a pediatric patient presenting to the emergency department

Pediatric retroclival hematomas

BACKGROUND

Traumatic retroclival hematomas (RCHs) are infrequent occurrences among the pediatric population. The existing body of research pertaining to these hematomas primarily consists of case reports or small case series, which do not provide adequate guidance for managing this condition.

OBJECTIVE

This study aims to present a report on four cases of RCHs. Additionally, we aim to conduct a systematic review to consolidate the existing literature on pediatric RCHs.

METHODS

The authors conducted a systematic review in accordance with the PRISMA and CARE guidelines. A multivariate logistic regression model was developed to evaluate the potential impact of various clinical variables on clinical outcomes. The study also documented four of our cases, one of which was a rare occurrence of spontaneous subdural RCH.

RESULTS

A total of 62 traumatic RCHs have been documented in the literature. We documented three cases of traumatic RCHs and one case of spontaneous RCH. A systematic analysis of 65 traumatic RCHs was performed. Of trauma cases, 64.6% demonstrated craniocervical junction instability with 83.3% ligamentous involvement. Thirty-five patients were males. 50.7% were aged between 5 and 9 years. Cranial nerve palsies occurred in 29 patients (27 had abducent palsy), 26 of which resolved within 6 months of trauma. 23.5% underwent surgery, and 76.5% were conservatively managed. Surgeries targeted hematomas, hydrocephalus, or craniocervical instability. Approaches to hematomas included transclival and far/extreme lateral suboccipital approaches. Clinical outcome was good in 75.4% and intermediate or poor in 24.6%. Logistic regression suggested an association between craniocervical junction injuries and poor or intermediate outcomes (OR 4.88, 95% CI (1.17, 27.19), p = 0.04).

CONCLUSION

Pediatric RCHs are mostly traumatic and extradural. Children between 5 and 9 years old are most vulnerable. Craniocervical junction injuries, mainly ligamentous, are common in RCHs and are associated with intermediate or poor outcomes. Cervical MRI could be important in cases of trauma to rule out ligamentous injuries of the craniocervical junction. The small size of RCHs should not exempt the careful assessment of craniocervical junction instability. Cranial nerve palsies are common and usually resolve within 6 months. Conservative treatment is typical unless brainstem compression, hydrocephalus, or craniocervical junction instability exists.

Atlanto-occipital dislocation in a child: a challenging diagnosis. Illustrative case

BACKGROUND

Atlanto-occipital dislocation (AOD) is a highly unstable injury of the osseoligamentous complex at the craniocervical junction that is more common in children. Its diagnosis remains a challenging process that must integrate clinical presentation and radiological criteria.

OBSERVATIONS

A 9-year-old child presented with severe craniocervical trauma (Glasgow Coma Scale score 6) and cardiorespiratory arrest on-site. Prompt resuscitation on-site and transfer to the university hospital were performed, and a computed tomography (CT) scan showed a subarachnoid hemorrhage around the brainstem and a retroclival hematoma. Most of the radiological criteria on CT scans for AOD were negative, except for the occipital condyle–C1 interval, and further imaging with magnetic resonance imaging permitted the diagnosis of AOD with rupture of both the tectorial membrane and the transverse ligament. Occipital-cervical Oc-C1–2 fixation was performed. The neurological outcome was excellent, with full recovery 6 months after the trauma.

LESSONS

AOD should be suspected in all high-intensity trauma in children, especially if the clinical presentation includes cardiorespiratory arrest and other brainstem and/or upper cervical cord symptoms along with premedullary subarachnoid hemorrhage. Understanding the ligamentous nature of the injury resulting in “normal” radiographs or CT scans is important to avoid underdiagnosing AOD, which can have detrimental consequences.

Traumatic Retroclival Epidural Hematoma

Retroclival epidural hematomas are particularly rare conditions that are frequently the result of high-energy, hyperflexion-hyperextension injuries in pediatric patients. We present the case of a 7-year-old previously healthy girl with traumatic retroclival epidural hematoma after a fall from a swing. She presented with a Glasgow Coma Scale score of 15 with severe neck pain and limitation of cervical movements in all directions. Radiological examination revealed retroclival epidural hematoma, and the patient was managed conservatively with good recovery. Although conservative management leads to good recovery in most cases, retroclival epidural hematomas should always be kept in mind regardless of the severity of trauma.

Association of Atlanto-Occipital Dislocation, Retroclival Hematoma, and Hydrocephalus: Management and Survival in a Pediatric Patient

Atlanto-occipital dislocation (AOD) is an injury with high morbidity and mortality. We present a case of survival of a pediatric patient with the diagnoses of AOD, retroclival hematoma, and resulting hydrocephalus. The patient's cervical spine was stabilized until occipital-cervical fusion provided definitive treatment, and the hydrocephalus was treated with a ventriculostomy. The patient survived with no neurological deficits. A better understanding and awareness of the radiologic criteria of AOD will lead to earlier recognition of AOD and improved outcomes, even in the presence of complications from AOD. Surgical fixation should be used for definitive treatment of injuries with AOD.

A major pitfall to avoid: retroclival hematoma due to odontoid fracture

BACKGROUND

Retroclival hematoma (RCH) is a rare occurrence. The hemorrhage is usually small and hidden and can be easily missed on CT scan. Here, we report the association of a RCH with an odontoid fracture.

METHODS

Case report and review of the literature.

RESULTS

We describe a case of a 75-year-old man with a history of squamous cell carcinoma of the tongue base, treated with chemo-radiation. He was on warfarin for atrial fibrillation. He presented to the hospital 6 weeks after falling from standing height, with headache, neck pain, and stiffness. Clinical examination did not show any focal neurologic deficits. INR measured 4 days before admission was 6.0, but therapeutic at 2.4 on the day of admission. CT scan of the head showed a RCH. CT angiogram of the neck unexpectedly showed a type II odontoid fracture with instability of the upper cervical spine and extension of the hematoma to the upper cervical spine. Anticoagulation was reversed with factor IX complex (Bebulin). He underwent C1-C2 fusion without any complications. The immediate post-operative period was unremarkable. Unfortunately, he succumbed to airway obstruction due to mucus plugging 14 days into hospitalization.

CONCLUSIONS

In the appropriate clinical setting, when a RCH is found, further imaging should be considered to rule out fracture of the cervical spine. Odontoid fractures can lead to compression of the spinal cord or lower medulla. To prevent neurologic injury and subsequent complications, prompt recognition of type II odontoid fracture should lead to immediate spine stabilization.

Normative data on axial rotation of atlanto-occipital joint on 3 Tesla MRI using a simple and reliable method of calculation

BACKGROUND

Various methods have been used to image and measure the normal range of axial rotation of the atlanto-occipital joint (AOJ), but a simple, precise, and reliable method is needed for everyday practice.

PURPOSE

To generate normative ranges for AOJ rotation in various in-vivo positions and to investigate the reliability of a simple imaging method for measurement using routine high-field magnetic resonance imaging (MRI).

MATERIAL AND METHODS

One hundred healthy volunteers were imaged on 3 T MRI with the AOJ in the center of the field of view. The scans were uniformly performed in seven different positions. The range of axial rotation was calculated by the angle between the craniofacial midline and the line linking the anterior and posterior tubercles of the atlas. The angle was defined as positive when it was angled right, and negative when it was angled left. The actual normative range of axial rotation was the difference between the angle in the supine neutral position and in the other positions.

RESULTS

The normative axial rotation range of the AOJ in different positions was between -4.8° and +5.0°. The mean values of the actual rotation angles in the right supine position with maximum bending, the right supine position maximum rotation, and the right prostrate position maximum rotation were 0.1°, 1.70°, and 0.8°, respectively. The mean values of actual rotation angles in the left supine position with maximum bending, the left supine position with maximum rotation, and the left prostrate positive with maximum rotation were 0.1°, -1.7°, and -1.1°, respectively. The inter-observer reliability tested.

CONCLUSION

A simple and reliable method of measurement on 3.0 T MRI demonstrated the normative axial rotation range of the AOJ in different positions to be between -4.8° and +5.0° and it was different from zero in neutral rotation. This method could be practically used to precisely diagnose AOJ rotary subluxation or dislocation.