SUMMARY Two children (aged 10 and 12 years) were admitted unconscious to a neurosurgical department after traffic accidents. Both developed a 6th nerve paralysis on the next day. One patient was able to communicate from the 2nd day and died on the 8th day in an anuric state without major neurological deficit. The second patient remained deeply comatose, tetraplegic, and required intermittent artificial respiration: She died of pneumonia on the 26th day. Neuropathological examination revealed a ponto-medullary rent in each case; additionally there was avulsion of small arteries over the pyramids, haemorrhage and small focal infarcts in the distribution of perforating arteries in the medulla and pons, and abundant retraction balls in longitudinal fibre tracts of the brain stem. The cases show for the first time that traumatic ponto-medullary tears are not always rapidly fatal, and demonstrate that primary focal brain stem trauma may occur in the absence of diffuse trauma of the white substance.Tears at the ponto-medullary junction as a result of severe cranio-cervical injury are well-recognised,'-5 but they are usually associated with almost instantaneous death. Accordingly, it has been argued by Adams and his group6-8 that primary damage to the brain stem as a result of a non-missile head injury does not occur in patients who survive their injury long enough to be transferred to a neurosurgical unit, and there is always diffuse damage to the white matter in such cases. The two cases documented in this paper, however, show that patients with primary traumatic ponto-medullary rents may survive for days or weeks after injury.
Case reportCase 1 This 10-year-old girl was found unconscious fastened in a safety belt after a 100 m crash down a steep slope sitting in a Lada Taiga car. On admission she was unconscious but reacted to pain. Extension spasms, bilateral extensor plantar responses and gaze deviation to the right were observed. She had a haematoma of the occiput and multiple bruises on her body. Radiographs and CT scan of the head were normal. On the cervical spine film there was a suspicion of an atlanto-axial subluxation. On the second day the child was able to communicate and now had paralysis of the 6th cranial nerve on the right side. One
The rare spinal subdural masses, usually haematomas, are described in 5 patients and the importance of ascending myelography in addition to computed tomography in radiological diagnosis is emphasised.
The case of a man, aged 67,who had bilateral occlusion of the cervical internal carotid arteries with an unusual collateral circulation between the occipital artery and the anterior cerebral artery, is described.
3 cases with fractures of cervical vertebra are presented in order to demonstrate the progress as well as the advantages of computed tomography in contrast to conventional x-ray examination.
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