920 Case Reports / Journal of Clinical Neuroscience 15 (2008) 920–922

patients and may change as experience grows with these rel-atively uncommon scenarios. It has been suggested that anappropriately designed multi-centre trial of intravenous hep-arin in acute stroke is overdue.10However, until that study iscompleted we feel that it is important to emphasize thatthrombolysis is the acute treatment for which there is thestrongest evidence and should therefore be considered inall patients presenting within 3 h of symptom onset, evenwhen extenuating circumstances such as this exist.

Acknowledgement

Dr. Allport is supported by an Australian NationalHealth and Medical Research Council Fellowship.

References

1. Adams HP, Brott TG, Furlan AJ, et al. Guidelines for thrombolytictherapy for acute stroke: A supplement to the guidelines for themanagement of patients with acute ischemic stroke. A statement forhealthcare professionals from a special writing group of the strokecouncil, American Heart Association. Stroke 1996;27:1711–8.

doi:10.1016/j.jocn.2007.03.026

Chiang-Wei Chou a,b, Wen-Cheng Huang a,b,Chantelle Wu d, He

a Department of Neurosurgery, Neurological Institub School of Medicine, National Yang

c Department and Institute of Pharmacology, School of Med Department of Physical Medicine and Rehabilitation,

Received 18 October 2006;

Abstract

Occipital condyle fracture is a rare and easily neglected fracture. Wneurological function. A young woman who had experienced a headdays later and a CT scan of the cervical spine revealed a type III left ocervical traction and 3 months of halo vest immobilization were appliethe bony fragment. The patient recovered well without adverse sequelaoccipital condyle fracture in trauma patients.� 2007 Elsevier Ltd. All rights reserved.

Keywords: Occipital condyle; Trauma; Fracture; CT

* Corresponding author. Present address: 17th floor, No. 201, Sec 2, Shih-PaE-mail address: hc_cheng@vghtpe.gov.tw (H. Cheng).

2. Tissue plasminogen activator for acute ischemic stroke. The NationalInstitute of Neurological Disorders and Stroke rt-PA Stroke StudyGroup. N Engl J Med. 1995;333:1581–7.

3. Hacke W, Kaste M, Fieschi C, et al. Intravenous thrombolysis withrecombinant tissue plasminogen activator for acute hemisphericstroke. The European Cooperative Acute Stroke Study (ECASS).JAMA 1995;274:1017–25.

4. Demchuk AM, Hill MD, Barber PA, et al. Importance of earlyischemic computed tomography changes using ASPECTS in NINDSrtPA Stroke Study. Stroke 2005;36:2110–5.

5. Goldhaber SZ. Thrombolysis in pulmonary embolism: a large-scaleclinical trial is overdue. Circulation 2001;104:2876–8.

6. Thomas MD, Chauhan A, More RS. Pulmonary embolism-an updateon thrombolytic therapy. QJM 2000;93:261–7.

7. Donnan GA, Davis SM. Heparin in stroke: not for most, but thecontroversy lingers. Stroke 2003;34:232–3.

8. The International Stroke Trial (IST): a randomised trial of aspirin,subcutaneous heparin, both, or neither among 19435 patients withacute ischaemic stroke. International Stroke Trial CollaborativeGroup. Lancet 1997;349:1569–81.

9. Camerlingo M, Salvi P, Belloni G, et al. Intravenous heparin startedwithin the first 3 hours after onset of symptoms as a treatment for acutenonlacunar hemispheric cerebral infarctions. Stroke 2005;36:2415–20.

10. Caplan LR. Resolved: heparin may be useful in selected patients withbrain ischemia. Stroke 2003;34:230–1.

Occult occipital condyle fracture with normal neurological functionand torticollis

Yang-Hsin Shih a,b, Liang-Shong Lee a,b,nrich Cheng a,b,c,*

te, Veteran’s General Hospital Taipei, Taiwan

Ming University, Taipei, Taiwan

dicine, National Yang-Ming University, Taipei, Taiwan

Taipei Veterans General Hospital, Taipei, Taiwan

accepted 20 March 2007

e describe a case of type III fracture with torticollis and normalinjury was suffering from neck pain. Torticollis developed several

ccipital condyle fracture. She had no neurological deficits. Externald. A follow-up CT scan showed good healing and re-attachment ofe. We conclude that physicians should be alert to the possibility of

i Road, Taipei 112, Taiwan. Tel.: +886 2 28757718; fax: +886 2 28757702.

Fig. 1. Axial CT scan of the cervical spine showing an avulsion fracture ofthe left occipital condyle and migration of the bony fragment into theforamen magnum.

Case Reports / Journal of Clinical Neuroscience 15 (2008) 920–922 921

1. Introduction

Occipital condyle fracture (OCF) is a rare injury thatis easily overlooked because it is not generally obviouson plain radiography. OCFs can be classified into threetypes: (i) comminuted; (ii) extension of basilar skull frac-ture; and (iii) condylar avulsion.1 Of these, type III isinduced by excessive rotation or lateral bending, and aco-existing ligament injury usually results in craniocervi-cal instability. If an unstable OCF is not recognizedand treated promptly, not only will neck pain persistbut lower cranial nerve palsy may also develop.2–4 Wereport a case of occult OCF that was not initially detected.Persistent neck pain and torticollis caused us to becomeconcerned. CT of the cervical spine confirmed a left-sidetype III OCF. Appropriate treatment was administered,the outcome of which was positive.

2. Case report

A 26-year-old woman presented with neck pain after atraffic accident. Cervical spine plain radiography revealeda C6 spinal process fracture and no other abnormal find-ings. The anterior prevertebral soft tissue width was with-in normal limits. The patient had no neurological deficits.She went home with a neck collar and took some analge-sics. However, her neck pain persisted and torticollisdeveloped thereafter. Upon examination, no other focalsigns could be found. A thin-cut high-resolution cervicalspine CT scan was performed, which revealed a left typeIII OCF with a bony fragment that had migrated intothe foramen magnum (Fig. 1). MRI revealed impairmentof the left alar ligament (Fig. 2, arrow). External cervicaltraction was applied to correct the torticollis, then thepatient underwent halo vest immobilization for 3 months.Her pain and torticollis quickly resolved. A follow-up CTscan showed re-attachment of the bony fragment with

Fig. 2. Axial (left) and saggital (right) T2-weighted MRIs of the cervical spinewas suspected.

callus formation (Fig. 3). The halo vest was removedand she recovered well.

3. Discussion

Since Anderson and Montesano’s pioneering study,1

OCF has been recognized and reported more often, espe-cially since CT scans have become more common fortrauma patients. Anderson and Montesano classifiedOCF into three types, with type III being the mostunstable.1 Tuli et al. also classified OCF into types 1,2A and 2B based on the degree of craniocervical instabil-ity and suggested rigid immobilization for type 2Bpatients.6 Thus, MRI may serve as a useful tool to

showing high signal change at the left alar ligament (arrow); a tearing injury

Fig. 3. Axial CT scan obtained 3 months after presentation showingre-attachment of the bony fragment and callus formation.

922 Case Reports / Journal of Clinical Neuroscience 15 (2008) 920–922

evaluate ligament injury and the resulting craniocervicalinstability.

The exact incidence of OCF is probably underesti-mated due to variations in symptoms and the fact thatit is not easily recognized on plain radiographs. High-resolution, thin-cut CT focusing at occipital-cervicaljunctions is the diagnostic tool of choice.5,6 Recently,Alcelik et al. proposed that plain radiographs focusingon prevertebral soft tissue width are helpful for detectingoccult OCF.7 Because CT is quick and convenient toperform, and provides detailed information, it has beenwidely accepted as the best diagnostic tool in traumapatients, and some centers even go directly to the CTscan without first using plain radiography. It is recom-mended that patients with a head or neck injury receive aCT scan for occult OCF if any of the following conditionsexist:

(1) excessive neck pain and no abnormality evident oncervical X-rays;

(2) lower cranial nerve palsy;(3) hemiquadraparesis in the absence of an intracranial

lesion;(4) cervical spine X-rays that reveal soft tissue swelling or

bony lesions.6

In our case, persistent neck pain and torticollis raisedour suspicions and a CT scan confirmed the diagnosis.MRI is well known for its ability to indicate the degreeof soft tissue injury. Its role in determining craniocervical

doi:10.1016/j.jocn.2007.03.014

stability in OCF patients also helps with the classificationof the disease.6 In our case, it revealed concomitant alarligament injury and further raised our concerns aboutinstability.

The treatment for OCF in our case was mainly conser-vative. There exists some debate about the best manage-ment approach for unstable cases,7 but it is generallyaccepted that some immobilization method should be used,and surgical decompression is rarely needed.3,6 If this con-dition is not recognized and treated early, delayed lowercranial nerve palsy may develop, especially in unstableOCF patients.2,4 This may be due to osseous and fibroustissue proliferation or further migration of bony fragmentsdue to instability.8 Thus, physicians should be alert to thepossibility of OCF and arrange appropriate examinationsand treatment when warranted.

4. Conclusion

We report a case of type III OCF that was missed dur-ing an initial hospital visit. Persistent pain and torticollisraised our suspicions and a CT scan confirmed the diag-nosis. MRI showed left alar ligament impairment. Cervi-cal traction and halo vest immobilization were applied.We suggest that more attention be paid to the possibilityof OCF and that when warranted, CT scans should bearranged promptly. Treatment is usually conservativeand surgery rarely required. If not recognized, seriouscomplications such as lower cranial nerve palsy or evendeath may occur.

References

1. Anderson PA, Montesano PX. Morphology and treatment of occipitalcondyle fractures. Spine 1988;13:731–6.

2. Bridgman SA, McNab W. Traumatic occipital condyle fracture,multiple cranial nerve palsies, and torticollis: a case report and reviewof the literature. Surg Neurol 1992;38:152–6.

3. Muthukumar N. Delayed hypoglossal palsy following occipital condylefracture: case report. J Clin Neurosci 2002;9:580–2.

4. Orbay T, Aykol S, Seckin Z. Late hypoglossal nerve palsyfollowing fracture of the occipital condyle. Surg Neurol 1989;31:402–4.

5. Bhalaik V, Fraser M. Fracture of the occipital condyle. Injury

2001;32:157–8.6. Tuli S, Tator CH, Fehlings MG. Occipital condyle fractures. Neuro-

surgery 1997;41:368–76., discussion 376–7.7. Alcelik I, Manik KS, Sian PS, et al. Occipital condylar fractures:

Review of the literature and case report. J Bone Joint Surg [Br]

2006;88-B:665–9.8. Hashimoto T, Watanabe O, Takase M. Collet-Sicard syndrome after

minor head trauma. Neurosurgery 1988;23:367–70.