Clivus fractures are usually associated with head blunt trauma due to traffic accident and falls. A 23–year-old
man died immediately after a smash-up while he was stopping on his motorcycle. Post-mortem Computed tomography (PMCT), performed before autopsy, revealed a complex basilar skull base fractures associated with
brainstem and cranio-vertebral junction injuries, improving the diagnostic performance of conventional autopsy.
Imaging data were re-assessable and PMCT offers the possibility to perform multiplanar and volume rendered
reconstructions, increasing forensic medicine knowledge related to traumatic injuries

A. Di Piazza

G. L. Aronica

G. Lo Re

R. Lagalla

S. Salerno

S. Zerbo

Archivio istituzionale della ricerca - Università di Palermo

Contents lists available at ScienceDirectLegal Medicinejournal homepage: www.elsevier.com/locate/legalmedUtility of post mortem computed tomography in clivus fracture diagnosis.Case illustration and literature reviewS. Zerboa,⁎, A. Di Piazzab, G. Lo Reb, G.L. Aronicaa, S. Salernob, R. Lagallaba Department for Health Promotion, Maternal and Child Care, University of Palermo, Section of Legal Medicine, ItalybDepartment of Radiology, University of Palermo, ItalyA R T I C L E I N F OKeywords:Post-mortem CTForensic pathologyClivus fractureTraﬃc accidentBrainstem lacerationCervical spineA B S T R A C TClivus fractures are usually associated with head blunt trauma due to traﬃc accident and falls. A 23 – year-oldman died immediately after a smash-up while he was stopping on his motorcycle. Post-mortem Computed to-mography (PMCT), performed before autopsy, revealed a complex basilar skull base fractures associated withbrainstem and cranio-vertebral junction injuries, improving the diagnostic performance of conventional autopsy.Imaging data were re-assessable and PMCT oﬀers the possibility to perform multiplanar and volume renderedreconstructions, increasing forensic medicine knowledge related to traumatic injuries.1. IntroductionThe clivus is the strongest bone of the skull base, provides me-chanical support for the cranial vault and protection for the brainstemand adjacent major vascular structures. Despite its deep location is verysusceptible to related fractures with consequent high mortality rate orpoor outcome for survivors [1,2].Clivus fractures may be observed in a serious head blunt trauma dueto traﬃc accidents and falls and the mortality rate and/or poor prog-nosis of the survivors is mainly due to concomitant injuries of thebrainstem [3–8], lower cranial nerves [1,9,10] and vertebro-basilarartery [1,11–14].In general, clivus fractures are diﬃcult to detected in both con-ventional and digital radiography, instead cross-sectional imagingtechniques as CT may detect fracture and add autoptic ﬁnding.As reported by Corradino et al. [15], the clival fractures are clas-siﬁed according their CT imaging as longitudinal, transverse and ob-lique. Longitudinal types are associated with the highest mortality(67–80%), related to the concomitant injuries of the brainstem, lowercranial nerves and vertebro-basilar artery. The oblique or transverseclival fractures have been often implicated in damage of the carotidarteries [1,15,16].The use of post mortem CT (PMCT), and the subsequent multiplanarand volume rendering reconstructions techniques, allows to obtain non-invasive, objective operator-independent imaging data set that could bealso reviewed by others specialists. PMCT with multiplanar (MPR) 3Dmaximum intensity projection (MIP) and volume renderedreconstructions images (VR), implement forensic knowledge related totraumatic injuries [17–19].2. Case historyWe report a case of a 23-year-old man who died immediately after asmash-up while he was stopping on his motorcycle. It was not possibleto exclude the presence of the helmet that was found far from the bodyin the accident site. The cause of death was related to a complex frac-ture of the skull base with brainstem and severe cranio-cervical injuries.3. Post mortem CT: technique and ﬁndingsThe post mortem interval between PMCT and the medico legalau-topsy was about six hours.PMCT was performed with a 128 slices MDCT scanner (SomatomDeﬁnition AS®, Siemens Healthcare Erlangen Germany). Volume ac-quisition was performed with thin collimation of 1mm. Scan para-meters were a tube voltage of 120 kVp, with an eﬀective tube current of120–160 eﬀective mAs, gantry rotation time of 0.5 s, beam pitch of 1.2and table speed of 46mm per gantry rotation.Images were reviewed using PACS (Elephant.net suite® AGFAHealthCare N.V., Belgium) and dedicated workstation (Singovia®Siemens Healthcare Erlangen Germany).During the reading sessions, axial and MPR images were reviewedwith a soft tissue and bone edge window manual adjustments madewhen needed.https://doi.org/10.1016/j.legalmed.2017.11.006Received 27 June 2017; Received in revised form 15 November 2017; Accepted 16 November 2017⁎ Corresponding author.E-mail addresses: stefania.zerbo@unipa.it (S. Zerbo), ambra_dipiazza@hotmail.it (A. Di Piazza), Giuseppe.lore12@gmail.com (G. Lo Re), gianluigiaronica@gmail.com (G.L. Aronica),sergio.salerno@unipa.it (S. Salerno), roberto.lagalla@unipa.it (R. Lagalla).Legal Medicine 30 (2018) 42–45Available online 16 November 20171344-6223/ © 2017 Elsevier B.V. All rights reserved.T3D-MIP and VR three-dimensional reconstructions were performedin the skull and cranial base. Data set of images obtained was thencompared with conventional autopsy report (Figs. 1–4).PMCT showed fracture of the occipital foramen reaching anteriorlyto the sphenoidal clivus and the mastoid on the left. The contralateralside of the occipital foramen was also involved. Fracture of plank headfrom the medial third of the occipital suture to left parietal bone nearorbital cavity, was identiﬁed. The PMCT scan also allowed to identifyodontoid process fracture, left atlanto-occipital diastase and anteriordislocation of C2. Nevertheless, the cervical spine was carefully ex-plored to exclude the presence of haemorrhage due to direct trauma.4. Autopsy ﬁndingsThe body was 168 cm in length weighing 63 kg. At external ex-amination only few bruises were found in the back on the left. Themacroscopic examination of the brain showed diﬀuse oedema, (brainweight: 1260 g). Subarachnoid haemorrhage of the base and a trau-matic laceration of brainstem were observed (Fig. 5). In serial cross-sections of the brain there was no evidence of intra-parenchymal hae-morrhages.A complex skull basilar fracture (Fig. 1) was detected in the PMCTinvestigation. Cervical spine was carefully explored and sectioned toexclude the presence of superﬁcial haemorrhage due to direct trauma.Other organs did not show any signiﬁcant abnormality.5. Histological ﬁndingsThere were haemorrhage and oedema around the brainstem la-ceration. No pathological evidence other than congestion was found.6. Toxicological analysisNeither drugs nor ethanol were detected by screening toxicologicalanalysis.7. DiscussionThere is some evidence on eﬀectiveness of digital autopsy in de-termining the cause of death due to blunt trauma [20–23]. Noteworthy,Kasahara et al. [24] reviewed 339 forensic autopsy cases observed thatcauses of death could be determined based on PMCT ﬁndings alone in7% of the cases, based on suggestive PMCT ﬁndings with additionalinformation in 54% and could not be determined in 38%.Fig. 1. 3D-MIP axial reconstruction image looking ideallythe skull from the neck (A) focused on skull base, clearlyshows bilateral clivus fracture (arrows) as conventionalautopsy (arrows) (B).Fig. 2. 3D-MIP coronal reconstruction comprehending the skull from the base to vertex,showing clivus fracture with high-conﬁdence in representing bone extremities detach-ment, particularly on the right side (arrow).Fig. 3. VR coronal skull reconstruction with posterior view, showing clivus fracture(arrow), separation between skull base and ﬁrst vertebra (*), abnormally rotate, betweenﬁrst and second vertebra, with consequent odontoid process fracture.S. Zerbo et al. Legal Medicine 30 (2018) 42–4543PMCT is becoming a commonly performed imaging examination inforensic medicine with the aim to identify the extension and localiza-tion of the skull base fractures and investigate the cranium cervicaljunction lesions, supporting conventional autopsy approach [20–24].Three-dimensional reconstruction of bone fractures can, also improvethe diagnostic accuracy, particularly of cervical spine examination[25]. Generally the presence of a cervical spine injury should induce aninvestigation (both conventional and/or digital X-ray and PMCT) be-cause contiguous spinal column injuries may occur in 10%–15% ofthese cases [25].In reported case, the cause of death was due to a complex skull basefractures associated with brainstem and cranio-vertebral junction in-juries without concomitant spine injuries. In trauma center the locali-zation of the head injuries, according with witnessed evidence, sug-gested a huge impact with subsequent violent anterior ﬂexion of thevictim neck may cause fractures of the clival region. These ﬁndings mayreﬂect diﬀerent mechanism of injury, whereby displaced fractures havea higher propensity for injury due to rotational force, causing liga-mentous failure and chip- ping of the clivus while sparing surroundingstructure [3].PMCT ﬁndings addressed the autopsy section approach making awide autopsy dissection of cervical spine unnecessary. PMCT ﬁndingsalso supported the autopsy evaluation of skull fractures, showing anexcellent concordance between both the approaches proving the utilityof performing a PMCT scan before conventional autopsy. On the otherhand, the conventional autopsy showed a traumatic laceration of thebrainstem, which was undetected by CT scan.In all cases in which the spine may be involved, it is important toperform PMCT scan for demonstrating bone lesions and underlinePMCT ﬁndings that may suggest the presence of major ligamentousinjuries. In fact, loss of the normal contours of the spine, is a relevantﬁnding in PMCT scan for pathologist that can be highlighted usingMPR, 3D-MIP and VR images. Retropharyngeal soft tissue swellinggreater than 5mm at a level of C3 raises the suspicion of an underlyinganterior arch fracture. The clivus, on a sagittal view, should point to-ward the tip of the odontoid process with the tip of the clivus within5mm of the odontoid. A separation greater than 5mm between theatlas and the occipital bone is also considered abnormal [26].Furthermore the identiﬁcation of intra cranial air [27], ﬂuid [28] inthe sinus or opaciﬁcation of the mastoid cells [27] should suggest thepresence of a fracture involving the cranial fossa. Accurate search ofthese ﬁndings can substantially improve the assessment of fractures[29]. The fractures of cranium-vertebral junction can be also suspectedwhen there is a cervical epidural hematoma, which is characteristicafter trauma [30].PMCT is rarely a substitute for conventional autopsy, while may bea signiﬁcantly support for forensic pathologist in determining injuriesin trauma victims and support evidence of the cause of death.References[1] A. Menkü, R.K. Koç, B. Tucer, A.C. Durak, H. Akdemir, Clivus fractures: clinicalpresentations and courses, Neurosurg. Rev. 27 (2004) 194–198.[2] A. Winkler-Schwartz, J.A. Correa, J. Marcoux, Clival fractures in a Level I traumacenter, J. Neurosurg. 122 (2015) 227–235.[3] O.P. Gautschi, P.R. Woodland, R. Zellweger, Complete medulla/cervical spinal cordtransection after atlanto-occipital dislocation: An extraordinary case, Spinal Cord.45 (2007) 387–393.[4] B.L. Zhu, L. Quan, K. Ishida, M. Taniguchi, S. Oritani, M.Q. Fujita, H. Maeda,Longitudinal brainstem laceration associated with complex basilar skull fracturesdue to a fall: an autopsy case, Forensic Sci. Int. 126 (2002) 40–42.[5] V. Zivković, S. Nikolić, D. Babić, F. Juković, The signiﬁcance of pontomedullarlaceration in car occupants following frontal collisions: A retrospective autopsystudy, Forensic Sci. Int. 10 (2010) 13.[6] V. Živković, S. Nikolić, Pontomedullary lacerations and concomitant injuries: areview of possible underlying mechanisms, Srp. Arh. Celok. Lek. 141 (2013)542–547.[7] H. Maeda, T. Higuchi, M. Imura, K. Noguchi, M. Yokota, Ring. fracture of the baseof the skull and atlanto-occipital avulsion due to anteroﬂexion on motorcycle ridersin a head-on collision accident, Med. Sci. Law 33 (1993) 266–269.[8] P. Guigui, M. Milaire, G. Morvan, B. Lassale, A. Deburge, Traumatic atlanto-occi-pital dislocation with survival: case report and review of the literature, Eur. Spine J.4 (1995) 242–247.[9] L. Bonilha, Y.B. Fernandes, J.P.V. Mattos, W.A.A. Borges, G. Borges, Bilateral in-ternuclear ophthalmoplegia and clivus fracture following head injury: case report,Arq. Neuro. Psiquiatr. 3 (2002) 636–638.[10] M. Katsuno, H. Yokota, Y. Yamamoto, A. Teramoto, Bilateral traumatic abducensnerve palsy associated with skull base fracture–case report, Neurol. Med. Chir. 7(2007) 307–309.[11] A. Bala, N. Knuckey, G. Wong, G.Y. Lee, Longitudinal clivus fracture associated withtrapped basilar artery: unusual survival with good neurological recovery, J. Clin.Neurosci. 11 (2004) 660–663.[12] Y. Taguchi, M. Matsuzawa, H. Morishima, H. Ono, K. Oshima, M. Hayakawa,Incarceration of the basilar artery in a longitudinal fracture of the clivus: case reportand literature review, J. Trauma 48 (2000) 1148–1152.[13] S. Sato, H. Iida, H. Hirayama, M. Endo, T. Ohwada, K. Fujii, Traumatic basilarartery occlusion caused by a fracture of the clivus-case report, Neurol. Med. Chir. 41(2001) 541–544.[14] V. Triolo, A. Argo, S. Zerbo, G. Bono, A. Bonifacio, P. Pugnetti, P. Procaccianti,Lethal rupture of post-traumatic aneurysm of the vertebral artery case report, J.Fig. 4. VR para-axial reconstruction of skull base through an internal view of the bonecomponents removing digitally the brain.Fig. 5. Brainstem laceration showing no haemorrhage.S. Zerbo et al. Legal Medicine 30 (2018) 42–4544Forensic. Leg. Med. 16 (2009) 168–171.[15] G. Corradino, A.L. Wolf, S. Mirvis, J. Joslyn, Fractures of the clivus: classiﬁcationand clinical features, Neurosurgery 27 (1990) 592–596.[16] G.P. Ochalski, R.M. Spiro, A. Fabio, A.B. 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Utility of post mortem computed tomography in clivus fracture diagnosis. Case illustration and literature review

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Utility of post mortem computed tomography in clivus fracture diagnosis. Case illustration and literature review

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