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Comminuted Basilar Skull Fracture in a Colt: Use of Computed Tomography to Aid the Diagnosis F

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Comminuted Basilar Skull Fracture in a Colt: Use of Computed Tomography to Aid the Diagnosis F EQUINE VETERINARY EDUCATION / AE / july 2011 327 Case Reporteve_158 327..332 Comminuted basilar skull fracture in a colt: Use of computed tomography to aid the diagnosis F. Beccati*, G. Angeli, I. Secco, A. Contini, R. Gialletti and M. Pepe Ospedale Veterinario Universitario Didattico, Università degli Studi di Perugia, Dipartimento di Patologia, Diagnostica e Clinica Veterinaria, Sezione di Chirurgia e Radiodiagnostica, Perugia, Italy. Keywords: horse; head trauma; computed tomography; diagnosis; skull fracture Summary horse, a fall and a kick from another horse are the most common causes of head trauma with consequent The case of a one-year-old colt with acute onset of neurological signs (Tietje et al. 1996; Feary 2007; McSloy neurological dysfunction and epistaxis after a traumatic et al. 2007; Mayhew 2009). Brain injury is usually a result of event is presented. After initiating emergency treatment, fracture of the skull bones, such as the stylohyoid and the the colt was anaesthetised for diagnostic imaging. basisphenoid-basioccipital bone (Tietje et al. 1996; Nout Radiographic examination of the head was suggestive of and Reed 2005), and these represent the most severe brain soft tissue opacity in the area of the guttural pouches, but injuries (Feary 2007). The degree of brain injury and was inconclusive about osseous involvement. A computed neurological dysfunction is variable and depends on the tomography (CT) scan, used to obtain further details, inertial load of the impact, the direction of the trauma and showed a comminuted basilar skull fracture with 2 the shape of the contusive object. displaced fragments that were not detected by Basisphenoid-basioccipital bone fractures are radiography. Because of the poor prognosis for survival frequently avulsion fractures and affect the weakest and return to athletic function, the horse was subjected areas, such as the insertion area of primary flexor muscles to euthanasia. CT imaging provided the most useful of the head (rectus capitis ventralis major and minor, and diagnostic information about type, localisation, extension longus capitis ventralis); the weakness of this area is due and severity of the basilar skull fracture. to the lack of lateral support of the foramen lacerum in horses (Ramirez et al. 1998; Feary 2007; McSloy et al. 2007). Introduction Skull fractures have a poor prognosis, and basilar skull fractures are associated with high morbidity and mortality Traumas of the central nervous system (CNS) are the most rates (Sweeney et al. 1993; Tyler et al. 1993; Ramirez et al. common causes of neurological diseases in horses; the 1998; McSloy et al. 2007). majority of cases show spinal trauma but the brain is only The diagnosis of skull fractures by radiographic et al et al rarely involved (Tyler . 1993; Feige . 2000). examination is difficult, especially if there is no displaced Contusion trauma of the skull can cause bone lesions and bone fragment, and radiographs are easily misinterpreted primary injury (mechanical) of the brain tissue; mechanical because the suture line between the basioccipital and injuries occur at the time of the impact and develop as basisphenoid bones remains open in young horses (<5 a consequence of the disruptive forces associated with years) (Ackeman et al. 1974; Feige et al. 2000; Johnson local and diffuse neuronal depolarisation. A primary and Kellam 2001; McSloy et al. 2007). neurological injury can be complete and nonreversible at The good resolution and sensitivity of computed the time of impact (Feary 2007). Only about half of the tomography (CT) makes it the optimal imaging technique horses that suffer head trauma present with CNS for straightforward diagnosis of skull fractures in horses and involvement, the others present with fractures and do not it should be used whenever possible in cases of suspicious et al show neurological clinical signs (Tietje . 1996; Feary fractures of the head. 2007). Collision with stationary objects or with another This case report describes an unusual comminuted fracture of the basisphenoid-basioccipital bone in which diagnosis was obtained with CT because the radiographic *Corresponding author email: [email protected] evidence was inconclusive. © 2010 EVJ Ltd 328 EQUINE VETERINARY EDUCATION / AE / july 2011 Case details History A one-year-old 200 kg Anglo-Arabian colt was presented to the Veterinary Teaching Hospital for head trauma. During basic training, the colt reared up, fell backwards and hit its head on the ground. The owner, who was a farm animal veterinary surgeon, reported that the colt had seizure-like activity and showed severe epistaxis and mouth bleeding. After the accident, the colt was unable to adopt the normal standing position and the owner immediately referred the colt to the hospital. The colt was sedated with xylazine hydrochloride (Megaxilor 20%)1 (0.6 mg/kg bwt i.v.) during transport to the hospital. * Clinical findings and clinical pathology At the time of admission, the colt was recumbent and Fig 1: Lateral view of the cranium revealing some irregular radiolucent lines over the basioccipital-basisphenoid bone showed moderate bilateral epistaxis and abnormal (arrow), and an increased soft tissue opacity in the area of the mentation; it was unresponsive to stimuli and had guttural pouches (asterisk). numerous abrasions and swellings located on the zygomatic arch, the zygomatic process of the frontal bone and around the orbit regions. The animal was sedated with xylazine hydrochloride (Megaxilor 20%)1 (0.5 mg/kg bwt i.v. 3 times in 2 h) for further evaluation of its clinical status. The colt’s mental status made a neurological examination difficult and evaluation of the cranial nerve and spinal cord reflexes was incomplete. The colt had absent pupillary light response (direct and consensual), reduced eyelid and corneal (blink) reflex and anisocoria, and the clinical laboratory findings showed only mild dehydration. The colt was fitted with protective facial shield apparatus2 and confined to a recovery box where it was maintained in pharmacological coma by administration of phenobarbital (Luminale)3 (bolus 20 mg/kg bwt i.v. over 30 min, then 9 mg/kg bwt i.v. q. 8 h for 1 day) for convulsion control and to perform primary treatment and diagnostic evaluation. Initial medical therapy consisted of Lactated Fig 2: Ventrodorsal view of the cranium. No abnormalities were 4 Ringer’s solution and 0.9% (w/v) sodium chloride detected. administered i.v. at the rate of 50 ml/kg bwt/h, and oxygen therapy (100%) at the rate of 15 l/min through insufflation. (Fig 2), the basioccipital-basisphenoid suture line was Dexamethasone 0.2 mg/kg bwt i.v. (Desashock)5 and identified and no abnormality was detected. Given the 10% (v/v) dimethyl sulphoxide 1 g/kg bwt i.v., were inconclusive radiographic findings, a CT scan was used in administered to reduce oedema and to control an attempt to obtain further details. The animal was laid inflammation and free radical scavenging, and the use of on a custom-made CT table and placed in dorsal mannitol was avoided. recumbency with the head positioned fully extended in After primary treatment and stabilisation, the colt the gantry, so that the longitudinal axis of the head and was placed under general anaesthesia to undergo the occlusal surface of the cheek teeth were parallel with radiographic examination. Radiographs of the lateral view the table and perpendicular to the gantry. of the skull were taken with the animal in the right lateral Computed tomography images were obtained with a position and ventrodorsal views of the skull were obtained fourth-generation helical CT scanner (Siemens Somatom in the dorsal recumbency position. In the lateral view Volume Zoom)6. The imaging parameters were 120 kV and (Fig 1), some small radiolucent lines over the basisphenoid 380 mA, with a pitch of 2.5 mm and slice thickness of bone and increased soft-tissue opacity in the area of the 2.5 mm. The scan length was 30 cm to ensure the inclusion guttural pouches was detected. In the ventrodorsal view of the nuchal crest and the last maxillary cheek teeth © 2010 EVJ Ltd EQUINE VETERINARY EDUCATION / AE / july 2011 329 * Fig 3: CT image (bone window) at the level of the temporomandibular joints revealing multiple longitudinal Fig 5: CT transverse image (bone window) at the level of the hypoattenuating lines within the basisphenoid bone (arrows). temporomandibular joints. One bone fragment is detached from the dorsal aspect of the basisphenoid bone (arrow). A hyperattenuating mass of soft tissue density is detached between the guttural pouches compressing the medial wall of the left guttural pouch (asterisk). * * Fig 4: CT transverse image (bone window) at the level of the inner ear revealing one fragment detached from the lateral aspect of the basisphenoid bone (arrow). A dense mass is detached Fig 6: CT transverse image (soft tissue window) at the level of the between the guttural pouches compressing the medial wall of the temporomandibular joint revealing haemorrhage compressing the left guttural pouch (asterisk). medial wall of the left guttural pouch (asterisk). (Triadan 11s). The scan direction was caudorostral and the recognised on survey radiographs and were located close images were evaluated using Osirix v3.5.1 DICOM view to the basioccipital-basisphenoid bones. Using a soft tissue software. Using a bone window, the CT scan showed window, a large soft tissue density between the guttural several irregular hypoattenuating linear gaps arcuate in pouches was detected extending from the tympanic bulla lateral and dorsoventral directions within the basisphenoid to the most caudal portion of the sphenopalatine sinus. This bone (Fig 3). At the level of the stylohyoid bones, CT mass was located in the area corresponding to the rectus evaluation revealed a large osseous fragment (17 ¥ 24 ¥ capitis ventralis and lungus capitis ventralis muscles and 3 mm) along the basisphenoid bone slightly displaced was consistent with haemorrhage between guttural laterally (Fig 4).
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