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BACKGROUND  Atlanto-occipital dislocation (AOD) is a highly unstable injury of the osseoligamentous complex at the craniocervical junction that is more common in children. Its diagnosis remains a challenging process that must integrate clinical presentation and radiological criteria.    OBSERVATIONS  A 9-year-old child presented with severe craniocervical trauma (Glasgow Coma Scale score 6) and cardiorespiratory arrest on-site. Prompt resuscitation on-site and transfer to the university hospital were performed, and a computed tomography (CT) scan showed a subarachnoid hemorrhage around the brainstem and a retroclival hematoma. Most of the radiological criteria on CT scans for AOD were negative, except for the occipital condyle–C1 interval, and further imaging with magnetic resonance imaging permitted the diagnosis of AOD with rupture of both the tectorial membrane and the transverse ligament. Occipital-cervical Oc-C1–2 fixation was performed. The neurological outcome was excellent, with full recovery 6 months after the trauma.    LESSONS  AOD should be suspected in all high-intensity trauma in children, especially if the clinical presentation includes cardiorespiratory arrest and other brainstem and/or upper cervical cord symptoms along with premedullary subarachnoid hemorrhage. Understanding the ligamentous nature of the injury resulting in “normal” radiographs or CT scans is important to avoid underdiagnosing AOD, which can have detrimental consequences.

Atlanto-occipital dislocation in a child: a challenging diagnosis. Illustrative case