Download Orbital Hematoma with Extradural Hematoma Presentating as Acute

Case Report
Orbital Hematoma with Extradural Hematoma
Presentating as Acute Proptosis following Head
Injury - A Rare Case Report
Dr. Pradeep Reddy, Dr Vipul Arora, Dr. Usha Kim, Dr. P.Subburam, Aravind Eye Hospital, Madurai
Introduction
Post traumatic proptosis due to orbital subperiosteal
hematoma is an uncommon entity. We report a
very rare case of post traumatic simultaneous
occurrence of subfrontal extradural hematoma
and orbital subperiosteal hematoma with orbital
roof fracture following head injury in a 15 year old
boy. This association has been reported previously
in only 10 cases and only one report has appeared
in the ophthalmic literature.(1-2) This case report
highlights the rarity of the combination of the
pathological lesions, and the need for having a high
index of suspicion of such, in a patient presenting
with post traumatic Proptosis and orbital roof
fracture.
Case Report
A 15-year-old village boy presented to our hospital
complaining of left-sided Proptosis, pain and
diplopia for the past 6 days. He sustained head
injury after a 3 meter fall from tree 13 days prior.
He had a lacerated wound at left temporal region
and left supraorbital region for which suturing
was done by local surgeon. He was observed for
24 hours for any neurological deficit and then
discharged. After 6 days he developed gradually
progressive left eye proptosis, pain and diplopia.
On examination the patient was fully conscious
with a normal affect and a Glasgow coma scale of
15/15. He had no neck stiffness, cranial nerve
palsy, or any other localising signs.
The visual acuity in the right eye was 6/9 and
in the left 6/60. On the left, non-axial proptosis
measuring 6 mm forwards, 5 mm downwards and
Fig : 1 (showing left eye gross eccentric proptosis)
5 mm laterally was present (fig1). Proptosis had no
bruit, non posture dependent, and no change with
the valsalva maneuver. Eyelids were unable to close
because of gross proptosis and chemosis leading to
corneal epithelial defect and crusting. Pupils were
normal and reacting. There was marked limitation
of elevation and depression, slight limitation of
abduction, and adduction. As the cornea was hazy,
fundus details were not made.
Axial section
Coronal section
Extradural hematoma
(5.75 x 4.53 x 3.30cm)
Superior subperiosteal
hematoma of orbital roof
(3.44 x 2.73 x 2.24cm)
Fig: 2 (CT showing left frontal extradural
haemorrhage & left superior orbital subperiosteal
haemorrhage)
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Computed tomography demonstrated a
superio-medially located orbital subperiosteal
hematoma (measuring 3.44 x 2.73 x 2.24cm), in
continuity with sub frontal extradural haematoma
(measuring 5.75 x 4.53 x 3.30 cm) through the
undisplaced orbital roof fracture in the left side
(fig 2).
Patient underwent left frontal craniotomy, and
a thick solid clot overlying floor of anterior cranial
fossa was evacuated (fig 3). However we could not
find the orbital roof fracture on table. Superior
orbitotomy was done and orbital subperiosteal
hematoma evacuated. Proptosis disappeared
immediately and periorbital swelling subsided over
a period of one week. Postoperatively the patient
Fig : 3 (Intraoperative)
Fig:4 (Post-operative)
made an uneventful recovery with no neurological
deficit, normal vision and fundus (fig 4).
Discussion
The differential diagnosis of acute proptosis
after head injury includes fracture of orbit with
retrobulbar haemorrhage, laceration and rupture
of the tissues of the orbit and extra ocular muscle,
AECS Illumination
carotid cavernous aneurysm in orbit. Post
traumatic progressive proptosis developing due to
subperiosteal haematoma is uncommon and even
rare is its association with sub frontal extradural
haemorrhage (3-4).
Extradural hematoma comprises about
1-2% of head trauma admission.(5).Extradural
hematomas mainly results due to bleeding from
the epidural vessels or the draining emissary vein.
(6) An extradural haematoma is a life-threatening
condition with a mortality rate in children is upto
50% (7). The clinical features of an extradural
haematoma include headache, vomiting,
drowsiness, loss of consciousness. Normal mental
status and normal neurological examination in the
presence of an extradural hematoma is extremely
rare (8). Of the previous reported case except
one all had loss of consciousness. C R Stewart,
J F Salmon, Z Domingo, A D Murray reported a
similar case with proptosis and headache in BJO
(2). But in our case patient presented with only
proptosis and diplopia.
Orbital subperiosteal hematoma presenting
as proptosis may be spontaneous or traumatic in
origin. The spontaneous hematoma is very rare (9).
Subperiosteal hematomas of the orbit typically are
a result of trauma to the head region. Roof of the
orbit is the most commonly involved site and is
more often seen in young males (10). Subperiosteal
hematomas on the roof of the orbit can be
explained as the frontal bone forms the largest
continuous concave bone surface of the orbit and
also orbital periosteum is not firmly attached to the
bony surfaces except at its suture lines. It may or
may not be associated with orbital roof fracture. A
somewhat delayed occurrence seems to be another
typical feature of subperiosteal hematoma of the
roof of the orbit (11). In our case also the child
presented late that was after one week.
Simultaneous occurrence of the subfrontal
extradural hematoma and subperiosteal hematoma
is very rare. Out of 8, one case was having
bilateral subperiosteal hematoma with subfrontal
extradural hematoma (12). As seen in our case
Vol. XIV, No.4, October - December 2014
many times size of the extradural hematoma is
bigger than the orbital subperiosteal hematoma
(10/13). Thus, the primary site of bleeding is
at subfrontal region either due to rupture of a
dural artery or an emissary vein and associated
subperiosteal hematoma is due to stripping of the
periorbita because of the orbital roof fracture or
seepage of blood through the fracture site from
subfrontal extradural hematoma.
In our patient, proptosis was caused by
a subperiosteal hematoma extending from a
subfrontal extradural hematoma through an
orbital roof fracture. This case illustrates that
an extradural hematoma along with orbital
subperiosteal hematoma can also be one possibility
for post traumatic proptosis even in the absence
of neurological signs. C.T scanning of the orbit
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and cranium is mandatory before embarking on
emergency orbital surgery. Thus the scan not
only reveals the orbital anatomy in detail but also
gives the opportunity to rule out any associated
intracranial hematoma which may alter the
surgical plan. It is important to diagnose early
extadural hematoma as it has high mortality.
Delayed diagnosis of orbital subperiosteal
hematoma may compromise visual function (13)
either due to exposure keratopathy (as in our case)
or compression of optic nerve. So it requires an
emergency surgical intervention for evacuation of
extradural hematoma through frontal craniotomy
and also subperiosteal hematoma via front-superior
orbitotomy simultaneously, thus preventing
further complications.
References
1. Sinkiewicz A, Kasprzak H,Kachki. Epidural hematoma with unilateral exophthalmos Neurol Neurochir
Pol. 1992;Suppl 1:349-52.
2. C R Stewart, J F Salmon, Z Domingo, A D Murray. Proptosis as a presenting sign of extradural
hematoma..British Journal of Ophthalmology 1993;77:179-180.
3. Batuk Diyora DNB (Neuro), Alok Sharma M Ch, Kaushik Patel MS.Simultaneous occurrence of
traumatic subfrontal extradural hematoma with orbital subperiosteal hematoma Indian Journal of
Neurotrauma 2006, Vol. 3, No. 2, pp. 139-141.
4. Umansky F, Pomenanz S. Epidural haematoma and unilateral exophthalmos. A review, Acta
Neurochir(Wein)1989;99:145-7.
5. Sharma AK, Diyora BD, Shah SG, Pandey AK, Sayal PP,Ingale HA, et al Orbital subperiosteal hematoma
associated with sub frontal extradural hematoma J Trauma 2007;62:523-5.
6. Stephanov S, de Preux J. Acute subfrontal epidural hematoma: Report of two cases. Surg Neurol 1992;
37:329-31.
7. Pasaoglu A, Orhon C, Koc K, Selcuklu A, Akdemir H, Uzunoglu H Traumatic extradural haematomas in
pediatric age group. Acta Neurochir(Wien) 1990; 106: 136-9.
8. Snyder HS, Salo D. Epidural hematoma: an unusual presentation. AmJ EmergMed 1990; 8: 538-41
9. Gruszkiewicz J. Ipsilateral exophthalmos in subfrontal epidural hematomas. Report of four cases. J
Neurosurg 37; 613-5.
10.. J. Reimer Wolter, MD Subperiosteal hematomas of the orbit in young males. Trans Am Ophthalmol Soc.
1979; 77: 104–120.
11.Costa JR, Leodante Batista da, Andrade et al. Traumatic bilateral intraorbital hematoma associated with
epidural hematoma: Case report. Arg Neuro-P siquiatr 2003;61:1039-41.
12.Nakai K, Doi E, Kuriyama T, Tanaka Y. Spontaneous subperiosteal hematoma of the orbit.
Surg Neurol 1983; 20:100-2