Traumatic bilateral intraorbital (subperiosteal) hematoma associated with epidural hematoma: case report

Hematoma intraorbitário bilateral traumático associado a hematoma epidural: relato de caso

Traumatic bilateral intraorbital (subperiosteal) hematoma associated with epidural hematoma: case report

Hematoma intraorbitário bilateral traumático associado a hematoma epidural: relato de caso

Leodante Batista da Costa Jr^I; Agustinho de Andrade^II; José Gilberto de Bastos Henriques^III; Anderson Finotti Cordeiro^III; Cícero do Juazeiro Job Maciel^III

Fundação Benjamin Guimarães - Hospital da Baleia, Belo Horizonte MG, Brazil, Fundação Hospitalar de Minas Gerais - FHEMIG - HPS João XXIII, Belo Horizonte, MG, Brazil

^INeurosurgeon, Hospital João XXIII, FHEMIG e Fundação Benjamin Guimarães

^IINeurosurgeon, Hospital João XXIII, FHEMIG

^IIIResidents of Neurosurgery, Hospital João XXIII, FHEMIG

ABSTRACT

Extradural hematoma (EDH) is a frequent lesion, with an incidence varying from 0.2 to 6% in patients admitted to hospital due to traumatic head injury. The higher incidence is found in patients with more severe injuries. The association of EDH with subperiosteal intraorbital hematomas is rarely reported, and we were not able to find in the literature any report of traumatic bilateral intraorbital hematomas and EDH. We report this case of a 32 year-old man with bilateral intraorbital (subperiosteal) hematoma associated with unilateral EDH. The lesions were treated surgically, but unfortunately with an unfavorable outcome.

Key words: extradural hematoma, head trauma, orbital hematoma.

RESUMO

Hematomas epidurais (HE) são lesões frequentes, com incidência entre 0,2 a 6% em pacientes internados após traumatismo cranioencefálico, sendo a maior incidência associada a pacientes portadores de traumas mais graves. A associação entre o HE e o hematoma intraorbitário é rara, sendo que não conseguimos encontrar na literatura nenhum relato de HE e hematoma intraorbitário bilateral. Relatamos o caso de um paciente de 32 anos com HE associado a hematoma intraorbitário bilateral, tratados cirurgicamente.

Palavras-chave: hematoma epidural, hematoma intraorbitário, traumatismo cranioencefálico.

Intraorbital hematomas are rare lesions, usually associated with ophtalmologic procedures, coagulation disturbances, or trauma. The presence of subperiosteal (extradural) hematomas of the orbit is rarely reported in the literature. These uncommon lesions are found after head and facial trauma, usually associated with an orbital roof fracture, and can lead to permanent blindness. We report the case of a man operated on to drainage of a large frontal epidural hematoma, presenting a few days after with dilated pupils and visual deficit, when bilateral subperiosteal intraorbital hematomas where diagnosed and drained. This is to our knowledge the first case of an extradural intracranial hematoma associated with bilateral intraorbital subperiosteal hematomas, and we stress here the dificult of this diagnosis in acute setting, especially with associated intracranial postraumatic lesions.

CASE

A 32-year old man was admitted to our trauma hospital with a history of a 3 meters fall. Neurological examination revelead Glasgow Coma Score of 11/15, no focal deficits, right otorrhagia and bilateral palpebral hematoma, that precluded pupillary examination. After the initial trauma evaluation and stabilization, he was submitted to an urgent CT scan, that showed a large right frontal exradural hematoma (EDH) and intracranial air (Figs 1 e 2). The frontal EDH was operated imediatelly. On the first postoperative day, the patient was alert and confused, with no other deficits. Five days after surgery, as the large bipalpebral hematoma slightly improved, ocular examination was possible and revealed proptosis and fixed dilated pupils, with no reaction to light. Ocular moviments were normal on the right eye and showed a slight paresis of all muscles on the left one. An urgent CT scan was performed, and bilateral intraorbital hematoma was diagnosed, that were not saw in the initial CT scan (Fig 3). The patient was submitted to bilateral frontoorbital craniotomies with opening of both orbital roofs. A fracture was noted in the roof of the left orbita. Opening of the orbital roof revelead bilaterally a moderate amount of coagulated blood, that was removed. Both hematomas were subperiosteal (epidural), and there was not periorbital tears. No active bleeding points were identified. After surgery, there was improvement of the bipalpebral hematoma, ocular moviments and proptosis. One month after surgery, the patient showed perception of light, but no further recuperation of visual function.

DISCUSSION

Orbital hematomas are classified by Landa¹ either as intraorbital or subperiostal. Subperiosteal hematomas of the orbit are rare lesions, reported in early literature as ''blood cyst''. Almost all cases are associated with trauma, although they can occur spontaneously, and children are more commonly affected, with an average age of onset of 17.3 years, occurring more frequently in men than women, with a 4.5:1 ratio reported by Pope-Pegram^1,2. Proptosis, downward globe displacement, ophtalmoplegia, chemosis, lid hematoma, subgaleal hematoma and visual dysfunction are the most commonly related clinical manifestations, that occur most often acutely or within days of the traumatic event, but have been reported as late as twenty years after minor orbital trauma. The differencial diagnosis should include carotid-cavernous fistulae, orbital subperiostal abcess, orbital roof fractures, frontal mucocele, sinusites, complication of orbital and sinus surgery, tumors (rhabdomyosarcoma, leukemia, lymphangioma) and coagulopathies. Most of these diseases can be excluded based on the history, physical and radiological examination. Chronic hematic intraorbital cysts may result from undiagnosed or untreated intraorbital hematomas^1-5.

The suggested mechanism of subperiosteal orbital hematomas is bleeding from subgaleal vessels, that enlarges and dissects the subgaleal space, extending to the orbita. A fracture of the orbital roof can dissect the periorbita and make room for blood to colect. In our case, one orbital roof was fractured, but not the other, and we could only suppose that the blood dissected the subperiosteal space coming from the frontal subgaleal space³. Concerning its cause, the subperiostal hematomas can be divided in four categories: traumatic, congestive, systemic and spontaneous. As already mentioned, they occur most often after trauma. Traumatic lesions may result from direct injuries to the orbit or its neighbourhood, and may also be secundary to thoracic trauma, that results in increased venous pressure in the jugular vein and orbital veins. Minor head trauma is also related to subperiosteal orbital hematomas.Congestive etiologies include weight lifting, scuba diving and strenuous exercise. Sinusitis, coagulophaties, complications of ophtalmologic procedures, sinus or cranial surgery, and even labor are related among the systemic causes. Spontaneous intraorbital hematomas without any predisposing factor are very rare^6-11.

When the hematoma presents as diplopia, proptosis or other symptons and signs, without loss of visual acuity or signs of elevated intraocular pressure, some authorities advocate a trial of conservative management, ranging from observation alone to topical use of timolol maleate and intravenous or oral carbonic anhydrase inhibitors (acetazolamide). The question of how long one should observe a patient who is complaining of only diplopia and proptosis is still unanswered. The subperiostal intraorbital compartment is a relatively avascular space, and it may take weeks for the hematoma to be absorbed. If there is any sign of increased intraocular pressure or decreased visual acuity, imediate evacuation of the hematoma is indicated. This can be accomplished throught neddle aspiration or orbital exploration and drainage. Neddle aspiration is less technically demanding, but has the disadvantages of possible rebleeding and of not allowing removal of clotted blood. With orbital exploration, the surgeon can stop any active bleeding, reduce possible orbital roof fractures, remove coagulated blood and to leave a drain, if necessary. We choose to approach the hematomas with craniotomies insteady of using any of the orbital approachs, obviously because we were much more comfortable in performing a craniotomy than any other facial or orbital approach, but other approaches to the orbit, such as a lateral craniotomy, can also be used successfully^1,2,3.

The unfavorable outcome of our patient, with blindness (at least up to the last follow-up visit), stresses the necessity of being aware to this uncommom but dangerous complication of head trauma, to make an early diagnosis and institute the effective treatment, enhancing the chances of visual preservation.

Received 20 May 2003, received in final form 15 July 2003. Accepted 19 July 2003

Dr. Leodante B. Costa Jr - Rua Três Corações 13/302 - 30480-110 Belo Horizonte MG - Brasil. E-mail: [e-mail]

• 1. Landa MS, Landa EH, Levine MR.Subperiosteal hematoma of the orbit: case presentation. Ophthal Plastic Reconst Surg 1988;3:189-192.
• 2. Pope-Pegram LD, Hamill MB. Post-traumatic subgaleal hematoma with subperiosteal orbital extension. Surv Ophthalmol 1986;30:258-262.
• 3. O'Neill OR, Delashaw JB, Phillips JP. Subperiosteal hematoma of the orbit associated with subfrontal extradural hematoma: case report. Surg Neurol 1994;42:308-311
• 4. Stewart CR, Salmon JF, Murray ADN. Proptosis as a presenting sign of extradural haematoma. Brit J Ophthalmol 1993;77:179-180.
• 5. Goldberg SH, Sassani JW, Parnes RE. Traumatic intraconal hematic cyst of the orbit. Arch Ophthalmol 1992;110:378-380.
• 6. Spence CA, Duong DH; Monsein L, Dennis MW. Ophthalmoplegia resulting from an intraorbital hematoma. Surg Neurol 2000;54:447-451.
• 7. Umansky F, Pomeranz SH, Epidural haematoma and unilateral exophtalmos a review. Acta Neurochir (Wien) 1989;99:145-147.
• 8. Lee KS, Bae HG, Yun IG. Bilateral proptosis from a subgaleal hematoma: case report. J Neurosurg 1988;69:770-771.
• 9. Wolter JR. Subperiosteal hematomas of the orbit in young males: a serious complication of trauma or surgery in the eye region. J Pediatr Ophthalmol Strabismus 1979;16:291-296.
• 10. Oruc S, Sener EC, Akman A, Sanac AS. Bilateral orbital hemorrhage induced by labor. Eur, J Ophthalmol 2001;11:77-79.
• 11. Pasaoglu A, Orhon C, Akdemir H, Uzunoglu H, Öktem S, Yardim S. Subperiosteal intraorbital haematoma following minor head trauma: case report. Acta Neurochirur (Wien) 1989;97:83-85.

Publication Dates

• Publication in this collection
  06 Jan 2004
• Date of issue
  Dec 2003

History

• Accepted
  19 July 2003
• Reviewed
  15 July 2003
• Received
  20 May 2003