Incarceration of the Basilar Artery in a Fracture of the Clivus

A 23-year-old man was rendered immediately unconscious in an automobile accident. Following tracheostomy and repair of a scalp laceration at a neighboring hospital he was referred to us 2 hours after the accident. Examination. The patient was a deeply comatose. His blood pressure was 110/70, pulse rate 76, and respirations regular at 15 per min. A well-repaired semicircular scalp laceration extended from the frontal region to the posterior parietal area on the right. There was no bleeding in the auditory canals. The pupils were constricted, nonreactive to light, and slightly unequal. The eyes were centrally fixed and without vestibulo-ocular reflexes (doll's head eye movements). Ophthalmoscopic examination was normal. Neither corneal, palatal, or gag reflexes could be elicited. Minimal spontaneous movement was present only in the right arm. Muscle tone and deep tendon reflexes were all slightly increased. Painful stimulation of the trunk or head produced extensor spasms. Bilateral Hoffman's reflexes were present but the Babinski response was absent. Abdominal and cremasteric reflexes could not be elicited. X-rays of the skull demonstrated only a linear right frontal fracture. Carotid angiography was normal with the posterior cerebral arteries filling via the posterior communicating arteries. Vertebral angiography was not