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Case 5 - Capo de Tutti Fractures

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So we're going to move from French with the Le Fort

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fractures and move to a little bit of Italian

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with the Capo de Tutti fractures.

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These are the big fractures that you shouldn't miss.

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Those are fractures that can lead to CSF leaks because in

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addition to having potentially intracranial hypotension,

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you have the possibility of meningitis as the fracture

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will communicate with the subarachnoid space.

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And these involve generally the ethmoid sinuses,

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the temporal bone and the sphenoid sinus.

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Then we have fractures that can lead to pseudoaneurysms.

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These are important fractures to note.

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Most commonly, I see,

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are the ones that involve the sphenoid sinus walls which

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communicate with the carotid artery walls, either

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in its petrous segment or its cavernous segment.

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And to a lesser extent,

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you see it with the lesser wing of the sphenoid

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and that is at the optic canal.

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And then we have fractures that can potentially

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disrupt the venous sinuses.

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And these generally are temporal bone and occipital bone

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fractures which can lead to transverse sinus thrombosis

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or rupture. And in the parasagittal location,

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you may affect the superior sagittal sinus.

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In general,

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temporal bone fractures are ones you don't want to miss.

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And sometimes I find the temporal bone fractures while

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I'm looking at the cervical spine thin section images,

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when they get as high as the temporal bones,

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you'll see opacification of the temporal bones,

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the mastoid air cells.

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And that might be the clue that the patient

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potentially has a temporal bone fracture.

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So as I mentioned,

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complications, when you have fractures that communicate

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between the paranasal sinuses and

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the intracranial compartment,

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here we see fractures involving the frontal sinus and the upper

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anterior ethmoid sinuses, these may lead to CSF leakage.

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If you find any type of pneumocephalus

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associated with a facial bone fracture,

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be wary of the potential for communication between the

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paranasal sinuses and the intracranial compartment

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that can lead to meningitis,

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meningoencephaloceles or even arterial/venous injury.

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Here's an example of a fracture which was involving the

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posterior wall of the frontal sinus and led to a large

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collection of air in the anterior epidural space.

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Here's one of the fractures that I always worry about,

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and that is a fracture involving the lateral wall of the sphenoid.

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When you see a fracture involving

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the lateral wall of the sphenoid,

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particularly at the cavernous portion

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of the internal carotid artery,

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you have to be concerned about the potential for injury

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to that cavernous internal carotid artery.

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In this case,

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you see a little out pouching of the left

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cavernous internal carotid artery.

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The artery itself looks a little bit ballooned out.

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This is a pseudo aneurysm of the left internal cavernous

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portion of the internal carotid artery secondary to trauma,

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associated with these sphenoid sinus

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fractures. At the same time,

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notice that this fracture looks like it's

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involving potentially the optic canal.

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Here's the lesser wing of the sphenoid.

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So optic canal fractures may injure the optic nerve with

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hematomas. So vascular injury as well as neuronal injury

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on the same case where you have fractures

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that cross the sphenoid sinus.

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Here's the arteriogram

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showing the coiling of that pseudoaneurysm that occurred

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secondary to the fracture on the left

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cavernous internal carotid artery.

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Here's a different case of a patient who has a CC fistula,

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secondary to trauma that crossed from the sphenoid sinus into the

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cavernous sinus and affected a laceration of the internal

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carotid artery that communicated with the cavernous sinus.

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So a post-traumatic CC fistula.

Report

Faculty

David M Yousem, MD, MBA

Professor of Radiology, Vice Chairman and Associate Dean

Johns Hopkins University

Tags

Neuroradiology

Head and Neck

Emergency

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