Fractures of the clivus: A contemporary series in the computed tomography era

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA.
Neurosurgery (Impact Factor: 3.62). 12/2009; 65(6):1063-9; discussion 1069. DOI: 10.1227/01.NEU.0000360154.18604.28
Source: PubMed


We report the morbidity and mortality associated with fractures of the clivus and discuss management approaches specific to this unique diagnostic entity.
We performed a boolean search of our electronic medical record database to identify patients with fractures of the clivus that were diagnosed using computed tomography of the head. A retrospective imaging and chart analysis was completed to further characterize the fractures and to analyze outcomes.
Between January 1999 and December 2007, 41 patients were identified with fractures of the clivus. We found a 0.21% overall incidence among all head-injured patients presenting to our institution and a 2.3% incidence among those patients with a cranial fracture. Ten of 41 patients (24.4%) died, and neurological and vascular complications associated with central cranial base fractures were observed in 19 of 41 patients (46%). Furthermore, associated cranial fractures remote from the central cranial base and associated intracranial hemorrhages were observed in 40 of 41 (97.6%) and 33 of 41 (80.5%) patients, respectively. In terms of outcomes, 26 of 41 patients (63.5%) had a Glasgow Coma Scale score of 12 or greater at the time of discharge from the hospital.
We demonstrate a lower than previously reported mortality rate in patients with clival fractures. Nevertheless, as a result of location, fractures of the clivus were frequently associated with a high rate of complications and neurological sequelae.

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    • "Clivus fractures are highly uncommon [1,2]. The classification by Corradino et al.[2] divides the different lesions in longitudinal, transverse and oblique fractures. "
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    ABSTRACT: Clivus fractures are highly uncommon. The classification by Corradino et al. divides the different lesions in longitudinal, transverse and oblique fractures. Longitudinal types are associated with the highest mortality rate between 67 - 80%. Clivus fractures are often found after high velocity trauma, especially traffic accidents and falls. The risk of neurologic lesions is high, because of the anatomic proximity to neurovascular structures like the brainstem, the vertebrobasilar artery, and the cranial nerves. Longitudinal clivus fractures have a special risk of causing entrapment of the basilar artery and thus ischemia of the brainstem. This lesion in our patient was a combination-fracture of the craniocervical junction with a transverse clivus fracture. In this case, the primary closed reduction of the clivus fracture and the immobilization with a halo device was the therapy of choice and led to consolidation of the fracture. Therapy advices and examples in the literature are scarce. We present a patient with a clivus fracture, who could be well treated by a halo device. Through detailed research of the literature a therapy algorithm has been developed.
    BMC Research Notes 12/2013; 6(1):554. DOI:10.1186/1756-0500-6-554
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    ABSTRACT: Fractures of the clivus and traumatic diastases of the clival synchondroses are rare in the pediatric population. The incidence, outcome, and biomechanics associated with these fractures have been difficult to ascertain secondary to the lack of literature pertaining to their occurrence. A Boolean search of the electronic medical record database at the Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, was performed to identify patients with fractures of the clivus that were diagnosed using CT of the head. A retrospective review of the chart and radiographic imaging was then performed to assess data regarding patient demographics, mechanism of injury, and skull and brain parenchymal injuries, as well as outcomes. Between May 2002 and November 2007, 16 patients with fractures of the clivus were identified. The mean age of these patients was 9 years (range 1-16 years). Eleven (68.8%) of the 16 patients had an associated traumatic diastasis of the central skull base. Five (31.3%) of the 16 patients died. However, of the 11 patients who survived, all had a good outcome with a Glasgow Outcome Scale score of 4 or 5 at the time of discharge. The incidence of clival fractures among patients with head injuries was 0.33%. Clival fractures occur with a similar incidence in both the pediatric and adult trauma population. Outcome is not correlated directly with the extent of clival fracture, but rather with the presenting Glasgow Coma Scale score and concomitant brain parenchymal injuries. The identification of traumatic diastases in patients with clival fractures suggests that static loading forces are a significant factor in the biomechanics producing these types of fractures.
    Journal of Neurosurgery Pediatrics 03/2011; 7(3):261-7. DOI:10.3171/2010.12.PEDS10190 · 1.48 Impact Factor
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    ABSTRACT: We aimed to show the significance of the anterior pontine membrane as a determining structure between the subdural and subarachnoid space in the clival region. MATERIAL and Five adult cadaver heads and five cerebral hemispheres were used. The skull vault and hemipheres were removed by sectioning through the pontomesencephalic junction. Five other heads hemispheres were removed but the arachnoid membrane was protected and the cerebral side of the clival dura mater was dissected. In another specimen, the dural porus of the abducens nerve was sectioned for histological evaluation. Three cases of hematoma at the clivus were presented to support our findings. The anterior pontine membrane is the arachnoid membrane forming the anterior wall of the prepontine cistern with its lateral extension at the skull base. This membrane forms the subdural and subarachnoid spaces by forming a barrier between the clival dura mater and neurovascular structures of the brainstem. There were rigid fibrous trabeculations between both cerebral and periosteal dural layers forming the basilar plexus as the interdural space in the clivus. The anterior pontine membrane separates the subdural and subarachnoid spaces at the clival region. The hematomas of the clival region require to be evaluated with consideration given to the existance of the subdural space.
    Turkish neurosurgery 07/2011; 21(3):372-7. DOI:10.5137/1019-5149.JTN.3913-10.1 · 0.58 Impact Factor
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