Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 59, Num. 3, 2011, pp. 463-464

Neurology India, Vol. 59, No. 3, May-June, 2011, pp. 463-464

Letter to Editor

Spontaneous resolution of spontaneous subperiosteal orbital hematoma

Srikant Balasubramaniam¹, Amit Mahore², Nitin Dange²

¹ Department of Neurosurgery, BYL Nair Hospital, Mumbai Central, Mumbai, India
² Department of Neurosurgery, KEM Hospital, Mumbai, India

Correspondence Address: Srikant Balasubramaniam Department of Neurosurgery, BYL Nair Hospital, Mumbai Central, Mumbai India srikantbala@yahoo.com

Date of Submission: 05-Jan-2011
Date of Decision: 11-Jan-2011
Date of Acceptance: 12-Jan-2011

Code Number: ni11132

PMID: 21743185

DOI: 10.4103/0028-3886.82733

Sir,

Orbital subperiosteal hemorrhage is rare, mostly seen in young males secondary to direct facial or orbital trauma. ^[1] Other causes include surgery around the orbit, sinusitis, vascular abnormalities, neoplasms, and idiopathic inflammatory orbital pseudotumor. ^[2] Truly spontaneous subperiosteal hematomas are very rare and very few cases have been described. The management of these patients includes orbitotomy, needle aspiration, or conservative management. ^[1],[3],[4]

A 35-year-old lady presented with a history of sudden onset of pain in the left eye associated with occasional diplopia on looking to the right since 5 days. She also noticed blackening around the left eye and had occasional vomiting. There was no history of trauma, medications, sinusitis, comorbidities, or surgeries. Examination revealed mild nonpulsatile proptosis of the left eye with mild medial gaze restriction. Bilateral ocular fundus examination were normal. Visual acuity was normal in both the eyes and pupils were equal and normally reactive. There was periorbital blackening of the left eye [Figure - 1]. The complete blood picture, blood biochemistry including the coagulation profile, was normal. Computed tomography (CT) scan of the brain showed an extraconal hyperdense collection in the medial aspect of the left orbit suggestive of fresh hematoma. The hematoma was confined to the medial wall of the orbit with no significant mass effect. Magnetic resonance imaging (MRI) of the brain and orbit showed an oval lesion in the left orbit medial to the medial rectus measuring 3.5 cm × 1.4 cm × 2.6 cm. The lesion was isointense on T1W image and hyperintense on STIR image suggestive of hematoma. The orbital wall showed mild enhancement on contrast administration. MR angiogram (MRA) showed normal intracranial and orbital vasculature [Figure - 2] and [Figure - 3].

She was managed conservatively in view of the stable neurological status and normal vision and was started on corticosteroids (inj. methylprednisolone 500 mg every 12 h for 5 days). There was a gradual decrease in pain severity and periorbital echmosis. The patient had significantly improved in her symptoms in 1-week time and was discharged. At 3-month follow-up, she has normal vision, normal external ocular movements, and no orbital pain. The periorbital echmosis and propotosis have resolved. Repeat MRI showed the resolution of hematoma with no mass effect in the orbit [Figure - 4].

Orbital hematomas can be intraorbital or subperiosteal and can be spontaneous or secondary to some underlying cause. In our patient, the subperiosteal hematoma was spontaneous. Spontaneous subperiosteal hematomas are extremely rare. ^{[1],[2],[4],[5],[6],[7],[8],[9],[10]} Reports of subperiosteal hematomas following aneurysm coiling and in association with liver disease have been documented. ^[3],[5] The presentation can be very acute or progressive. ^[2],[6] Clinical features include sudden onset of proptosis, severe orbital pain, downward or lateral displacement of the affected eyeball, moderately decreased visual acuity, restricted ocular movement, and discoloration of the eyelid. ^[7] Diagnosis can be established by either CT or MRI.Digital subtraction angiography or MR angiography may be necessary to exclude vascular malformations. ^[2] In our patient, contrast MRI showed orbital wall enhancement. Probably, it may be secondary to inflammation (Orbital pseudotumor). An orbital pseudotumor with a sudden onset of hemorrhage has been reported. ^[8] The initial treatment is high-dose corticosteroids and close clinical monitoring for any deterioration. ^[2] Most of the patients described in the literature had surgical decompression by orbitotomy or endoscopic decompression [Table - 1]. We suggest an adequate trial of conservative management before surgical decompression in patients who are neurologically preserved.

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