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Progressive midbrain clefts after head trauma and decompressive surgery: a report of two patients
  1. Padma John Pramila1,
  2. Pavithra Mannam2,
  3. Ari George Chacko3 and
  4. Rohit Ninan Benjamin1
  1. 1Neurology, Christian Medical College Vellore, Vellore, Tamil Nadu, India
  2. 2Radiology, Christian Medical College Vellore, Vellore, Tamil Nadu, India
  3. 3Neurosurgery, Christian Medical College Vellore, Vellore, Tamil Nadu, India
  1. Correspondence to Dr Rohit Ninan Benjamin; rohit.benjamin{at}


This report describes two patients with acute-onset ptosis, oculomotor dysfunction, ataxia and drowsiness, referable to the midbrain tegmentum. Both patients had previously suffered severe closed head injuries requiring craniotomy for cerebral decompression. Serial brain scans in both cases revealed a newly developing cleft in the midbrain, with features suggestive of abnormal cerebrospinal fluid (CSF) flow across the aqueduct. A trial of acetazolamide was initiated to reduce CSF production, followed by a third ventriculostomy for CSF diversion in one patient, which resulted in arrested disease progression and partial recovery. There are only two previous reports in the literature of midbrain clefts that developed as remote sequelae of head trauma. We postulate that altered CSF flow dynamics in the aqueduct, possibly related to changes in brain compliance, may be contributory. Early recognition and treatment may prevent irreversible structural injury and possible death.

  • trauma CNS /PNS
  • neurological injury
  • cranial nerves
  • brainstem / cerebellum

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  • Contributors RNB, AGC and PM helped with the conception or design of the work. PJP, RNB and PM collected the data. RNB, PM and AGC analysed and interpreted the data. PJP and RNB drafted the article. AGC and PM provided critical revision of the article. RNB, AGC, PM and PJP provided final approval of the version to be published.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Parental/guardian consent obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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