Abstract
A male patient in his 50s had a head-on collision while driving. Prehospital emergency services recorded pulseless electrical activity on an electrocardiogram, and chest compressions were initiated. Before hospital arrival, return of spontaneous circulation was achieved after 17-min resuscitation during transport. His Glasgow Coma Scale score was 6, with unequal-size pupils unresponsive to light stimuli. A head computed tomography scan revealed a left acute subdural hematoma with a marked midline shift, and computed tomography of the cervical spine showed that the atlanto-occipital and atlanto-axial joint spaces were significantly widened. Initially, an emergency decompressive craniectomy for hematoma evacuation was performed, followed by posterior cervical fixation surgery in the subacute phase. After brain surgery, neurocritical care management was implemented for brain protection. Cervical spine magnetic resonance imaging revealed multiple ligament injuries at the craniovertebral junction, which confirmed the diagnosis of atlanto-occipital and atlanto-axial dislocation. On day 9, posterior fixation from the occiput to the fourth cervical vertebrae was performed. Subsequently, he was transferred to a rehabilitation hospital on day 45. No neurological sequelae were noted except for the neck rotation limitations due to the fixation surgery, and he could return to his previous job. Although craniovertebral junction ligamentous injuries are rare, they may coexist with severe traumatic brain injury. A careful reading of preoperative images focusing on the inter-joint space is important to detect craniovertebral junction ligamentous injuries in patients with traumatic brain injury inflicted with high-energy trauma.