Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 58, Num. 4, 2010, pp. 637-641

Neurology India, Vol. 58, No. 4, July-August, 2010, pp. 637-641

Brief Report

Concomitant occurrence of subfrontal extradural hematoma and orbital subperiosteal hematoma: A rare entity

Nayak Naren, Diyora Batuk, Kamble Hanmant, Modgi Rahul, Sharma Alok

Department of Neurosurgery, L.T.M.G. Hospital, Mumbai

Correspondence Address:Department of Neurosurgery, L.T.M.G. Hospital, Mumbai, Department of Neurosurgery, 2nd Floor, L.T.M.G. Hospital, Sion (W), Mumbai-400 022

Date of Acceptance: 31-Jan-2010

Code Number: ni10168

PMID: 20739812

DOI: 10.4103/0028-3886.68685

Abstract

Keywords: Extradural hematoma, orbital subperiosteal hematoma, sub frontal hematoma

Introduction

Extradural hematomas (EDH) account for 0.2 to 6% of traumatic brain injury hospital admissions. ^[1] The common locations are temporal, parietal, frontal, occipital, and posterior fossa. Sub-frontal is a very rare location. ^[2] Orbital extradural hematomas, orbital subperiosteal hematomas, are also uncommon. The presenting fearures are proptosis and visual symptoms. Simultaneous occurrence of sub frontal extradural hematoma and orbital subperiosteal hematoma is extremely rare and only eight such cases have been reported. ^{[1],[3],[4],[5],[6],[7],[8],[9]} We report our experience with four such patients.

Case Report

Retrospective analysis of case records of four patients with sub frontal extradural hematoma and orbital subperiosteal hematoma managed between January 2002 and December 2005 is presented [Table - 1] and [Table - 2].

Results

These lesions accounted for 0.2 % of all patients with traumatic brain injury operated during the study period. All were males in the second decade, mean age 12.7 years. Three patients presented two weeks after injury and one patient within a few hours. The injury was trivial in three patients and one had fall from a train. All patients had non-axial proptosis, 4 to 6 mm, with eye ball pushed downwards. Periorbital swelling was the presenting feature in one patient while three had history of the same. Periorbital swelling started on an average on the third day of injury and disappeared by day-7. In three patients, actual onset of proptosis was not clear but it became more prominent as periorbital swelling started receding. Two patients had ptoptosis with conjunctival congestion. All patients had visual disturbances, but visual acuity was normal in two patients. Of the other two patients, one had acuity of 6/60 and the other 6/24. Fundoscopic examination was normal in all the patients.

Computed tomography (CT) scan was performed in three patients [Figure - 1]a,b,c and magnetic resonance imaging (MRI) in one [Figure - 2]a, b, c. In all the four patients imaging showed both sub frontal extradural and orbital sub periosteal hematomas. In three patients CT scan showed an orbital roof fracture which was confirmed at operation. In the patient, who had MRI, fracture was evident at operation. The indications for evacuation of the hematoma were progressive visual failure in three patients and deteriorating sensorium in one patient. The size of the subperiosteal hematoma was significant in the three patients with visual symptoms. All underwent superior orbitotomy and extradural hematoma evacuation. The hematoma was solid in two patients, semi solid in one and liquid in one. There was immediate reduction in the proptosis following surgery in cases one and two. By day-10, proptosis disappeared and vision improved to normal in all the patients [Figure - 3]a and b. All the patients were asymptomatic at one year follow-up.

Discussion

First description of subfrontal extradural hematoma was by Jacobson. ^[10] Subfrontal location of EDH is often lethal because it is frequently unrecognized. Source of bleeding is often venous or from small arteries, which explains the slow clinical evolution. ^[3] It is rarely associated with pupillary abnormalities and other focal deficits. In our series, in three patients, sub frontal extradural hematoma was an incidental finding while the patients were being evaluated by CT/MRI scan for post traumatic proptosis. The other patient was fully conscious at admission, CT scan done after 24 h for deterioration in the conscious level revealed the hematoma. Presenting features of EDH include headache, focal deficits, changes in consciousness. Unusually, proptosis may be the presenting symptom of sub frontal extradural hematoma. ^{[5],[11],[12],[13],[14],[15]} The proposed mechanism for proptosis is direct compression of cavernous sinus and ophthalmic vein by the epidural hematoma leading to a retrograde congestion of intraorbital tissues. ^[11],[13] Direct compression of the periorbital tissues by the hematoma secondary to fracture of the orbit might be another mechanism. ^[13] In our series, in three patients it was the radiological evaluation for proptosis that revealed the sub frontal hematoma.

Orbital hematomas are rare and may be spontaneous or post-traumatic and are intraorbital or subperiosteal in location. ^[16] Subperiosteal hematomas are uncommon and mainly result from direct orbital and facial trauma or surgery. ^[17] They have usually acute onset, but delayed onset has also been described. ^[18] Proptosis is the presenting symptom in both but non-axial proptosis results from subperiosteal hematoma. Patient often seeks medical attention for proptosis which is often due to orbital pathology and rarely due to sub frontal extradural hematoma. Proptosis due to both orbital and sub frontal extradural hematoma is rare. ^{[1],[3],[4],[6],[7],[9]} Of the ten patients reviewed, eight were in the second decade and except one all were male. Magnitude of the trauma was not significant in all the cases. Proptosis was the presenting feature in seven of the ten patients [Table - 1] and [Table - 2]. We believe that the injury over forehead, mainly the supraorbital margin might have transferred the impact to the orbital roof and resulted in fracture of the same. Fracture of the orbital roof might have resulted in rupture of venous channels together with separation of the periorbita and dura from the bone with slow collection of the venous blood in the extradural space. In three of our patients the proptosis evolved slowly over a period of time and in one patient it was associated with the periorbital swelling and small amount of the blood in the orbit. We believe that a slow seepage of liquefied blood into the subperiosteal space under the effect of the gravity and raised intracranial pressure through paper thin orbital roof results in the orbital subperiosteal hematoma. With the experience of the earlier three patients we made it a policy to ask for orbital cuts in young patients with the sub frontal hematoma, this helped us to pick-up the condition in case 4. High index of suspicion is required as any delays in the diagnosis of subperiosteal hematoma may result in permanent vision loss.

Frontal craniotomy and superior orbitotomy are the standard treatment in a symptomatic patient. Surgical decompression resulted in good vision recovery in all the patients except in the patient who had bilateral subperiosteal hematoma [Table - 1] and [Table - 2]. However, superior orbitotomy may not be required in patients with no visual symptoms and in whom the diagnosis is established early. In such patients frontal craniotomy alone will be sufficient to reduce the intracranial pressure and prevent the progress of subperiosteal hematoma and also proptossis. ^[5] In these patients the outcome is generally good without mortality.

References

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