Retroclival Pneumocephalus Associated with Bilateral Abducens Palsy in a Child

Abstract

Traumatic brain injury (TBI) is less common in children than in adults. Posterior fossa lesions are even more uncommon, but, when present, are usually epidural hematomas. These lesions, even when small, may have a bad outcome because of the possibility of compression of the important structures that the infratentorial compartment contains, such as the brainstem and cranial nerves, and the constriction of the fourth ventricle, causing acute hydrocephalus. Although unusual, posterior fossa lesions are increasingly being diagnosed because of the better quality of and easier access to cranial tomography. In this paper, we report a case of a 12-year-old male patient who had suffered a TBI and presented with several pneumocephali, one of them in the retroclival region, causing a mass effect and then compression of the sixth cranial nerve which is the most susceptible to these injuries. We discuss these traumatic posterior fossa lesions, with an emphasis on retroclival pneumocephalus, not yet described in the literature in association with bilateral abducens palsy. In addition, we discuss associated lesions and the trauma mechanism.

Treatment options for traumatic abducens nerve injury: a dual-center clinical experience

“…Damage to the abducens nerve results in weakness of the innervated lateral rectus muscle, leading to exotropia or diplopia, and severe cases may present with compensatory head posture. Unilateral abducens nerve palsy is more common than bilateral cases and presents with either complete or partial paralysis [24] . Symptoms include esotropia of the affected eye, restricted or absent outward eye movements, compensatory head tilting toward the affected side, and xation of the gaze toward the unaffected side.…”

Bilateral abducens palsy in closed head injury: A comprehensive review of literature based on a case report

“…The most common associated nerves involved along with bilateral abducens nerve injury are facial and hypoglossal nerves. [21][22][23][24][25][26][27][28][29] Other nerves involved according to literature review were oculomotor, trochlear, trigeminal nerves. 18,30,31 Cases with retroclival extradural haematoma had higher chances of multiple cranial nerve injuries.…”

Air in the Subdural Space at the Clivus

“…This means that the potential subdural space exists at the calvarium [7] ; however, it forms a real space at the skull base filled by cerebrospinal fluid [8] . Figure 2 in the article by Paiva et al [1] indicates that the large air mass is not distributed in the subarachnoid space of the anterior pontine membrane. The arachnoidal membranous barrier formed by the anterior pontine membrane between the cerebrospinal fluid and air was observed on the sagittal CT image.…”

“…This suggests that the location of the air was in the subdural space where the nerves do not have direct contact with the air. We believe that the nerves were proDear Editor, We read the article by Paiva et al [1] with great enthusiasm. We are inquiring about their response on some points made in the article and would like to address several of their statements.…”

“…The authors describe the Dorello canal as "the triangular space defined by the apex of the petrous bone, the posterior clinoidal process of dorsum sellae, and Gruber's ligament" [1] . However, multiple descriptions of the Dorello canal exist in the literature.…”