Arq Neu ro p siq u iat r 2003;61(4):1039-1041
TRAUM ATIC BILATERAL INTRAORBITAL
(SUBPERIOSTEAL) HEM ATOM A ASSOCIATED
WITH EPIDURAL HEM ATOM A
Case rep o rt
Leodant e Bat ist a da Cost a Jr
1, Agust inho de Andrade
2,
José Gilbert o de Bast os Henriques
3, Anderson Finot t i Cordeiro
3,
Cícero do Juazeiro Job M aciel
3ABSTRACT - Extrad ural hem atom a (EDH) is a freq uent lesion, w ith an incid ence varying from 0.2 to 6% in p atients ad m itted to hosp ital d ue to traum atic head injury. The hig her incid ence is found in p atients w ith m ore severe injuries. The association of EDH w ith sub p eriosteal intraorb ital hem atom as is rarely rep orted , and w e w ere not ab le to find in the literature any rep ort of traum atic b ilateral intraorb ital hem atom as and EDH. We rep ort this case of a 32 year-old m an w ith b ilateral intraorb ital (sub p eriosteal) hem atom a associated w ith unilateral EDH. The lesions w ere treated surg ically, b ut unfortunately w ith an unfavorab le outcom e.
KEY WORDS: extrad ural hem atom a, head traum a, orb ital hem atom a.
Hematoma intraorbitário bilateral traumático associado a hematoma epidural: relato de caso
RESUMO - Hem atom as ep id urais (HE) são lesões freq uentes, com incid ência entre 0,2 a 6% em p acientes internad os ap ós traum atism o cranioencefálico, send o a m aior incid ência associad a a p acientes p ortad ores d e traum as m ais g raves. A associação entre o HE e o hem atom a intraorb itário é rara, send o q ue não conseg uim os encontrar na literatura nenhum relato d e HE e hem atom a intraorb itário b ilateral. Relatam os o caso d e um p aciente d e 32 anos com HE associad o a hem atom a intraorb itário b ilateral, tratad os cirurg icam ente.
PALAVRAS-CHAVE: hem atom a ep id ural, hem atom a intraorb itário, traum atism o cranioencefálico.
Fu n d ação Ben jam in Gu im arães - Ho sp it al d a Baleia, Belo Ho rizo n t e MG, Brazil, Fu n d ação Ho sp it alar d e Min as Gerais - FHEMIG - HPS Jo ão XXIII, Belo Ho rizo n t e, MG, Brazil: 1Neu ro su rg eo n , Ho sp it al Jo ão XXIII, FHEMIG e Fu n d ação Ben jam in Gu im arães; 2Neu ro su rg eo n , Ho sp i-t al Jo ão XXIII, FHEMIG; 3Resid en t s o f Neu ro su rg ery, Ho sp it al Jo ão XXIII, FHEMIG.
Received 20 May 2003, received in fin al fo rm 15 Ju ly 2003. Accep t ed 19 Ju ly 2003.
Dr. Leodant e B. Cost a Jr - Rua Três Corações 13/302 - 30480-110 Belo Horizont e M G - Brasil. E-mail: leodant e@t erra.com.br
In t rao rb it al h em at o m as are rare lesio n s, u su ally asso ciat ed w it h o p h t alm o lo g ic p ro ced u res, co ag u lat io n d ist u rb an ces, o r t rau m a. Th e p resen ce o f su b -p erio st ea l (ext ra d u ra l) h em a t o m a s o f t h e o rb it is rarely rep o rt ed in t h e lit erat u re. Th ese u n co m m o n lesio n s are fo u n d aft er h ead an d facial t rau m a, u su -ally asso ciat ed w it h an o rb it al ro o f fract u re, an d can lead t o p erm an en t b lin d n ess. We rep o rt t h e case o f a m an o p erat ed o n t o d rain ag e o f a larg e fro n t al ep id ural hem atom a, p resenting a few d ays after with d ilat ed p u p ils an d visu al d eficit , w h en b ilat eral su b -p erio steal in trao rb ital h em ato m as w h ere d iag n o sed an d d rain ed . Th is is t o o u r kn o w led g e t h e first case o f an ext rad u ral in t racran ial h em at o m a asso ciat ed w ith b ilateral intraorb ital sub p eriosteal hem atom as,
an d w e st ress h ere t h e d ificu lt o f t h is d iag n o sis in acu t e set t in g , esp ecially w it h asso ciat ed in t racran ial p o st rau m at ic lesio n s.
CASE
1040 Arq Neu ro p siq u iat r 2003;61(4)
hem atom a slightly im proved, ocular exam ination was pos-sible and revealed proptosis and fixed dilated pupils, with no reaction to light. Ocular m ovim ents were norm al on the right eye and showed a slight paresis of all m uscles on the left one. An urgent CT scan was perform ed, and bilateral intraorbital hem atom a was diagnosed, that were not saw in the initial CT scan (Fig 3). The patient was subm itted to bilateral frontoorbital craniotom ies 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 m o-derate amount of coagulated blood, that was removed. Both hem atom as were subperiosteal (epidural), and there was n o t p e rio rb it a l t e a rs. No a ct ive b le e d in g p o in t s w e re identified. After surgery, there was im provem ent of the bi-palpebral hem atom a, ocular m ovim ents and proptosis. One m onth after surgery, the patient showed perception of light, but no further recuperation of visual function.
DISCUSSION
Orb ital hem atom as are classified b y Land a1 either as in t rao rb it al o r su b p erio st al. Su b p erio st eal h em a-t o m as o f a-t h e o rb ia-t are rare lesio n s, rep o ra-t ed in early lit e ra t u re a s “b lo o d cyst ”. Alm o st a ll ca se s a re a sso cia t ed w it h t ra u m a , a lt h o u g h t h ey ca n o ccu r sp o n t a n eo u sly, a n d ch ild ren a re m o re co m m o n ly affected , w ith an averag e ag e of onset of 17.3 years, occurring m ore freq uently in m en than wom en, with a 4.5:1 rat io rep o rt ed b y Po p e-Peg ram1,2. Pro p to sis, d o w n w a rd g lo b e d isp la cem en t , o p h t a lm o p leg ia , ch em o sis, lid h em at o m a, su b g aleal h em at o m a an d
Fig 1. Right f ront al epidural hemat oma and int racranial air. Import ant edema of ext racranial sof t t issues can be not ed.
Fig 3. CT scan about one w eek af t er t he surgical evacuat ion of t he f ront al epidural hemat oma, show ing t he bilat eral int raorbit al hemat oma and a small right t emporal epidural hemat oma. Fig 2. A low er slice, show ing t he f ront o-basal ext ension of t he hemat oma, and again, int racranial air. A t emporal f ract ure, unrelat ed t o t he hemat oma, may also be seen.
Arq Neu ro p siq u iat r 2003;61(4) 1041
rep o rt ed as lat e as t w en t y years aft er m in o r o rb it al traum a. The d ifferencial d iag nosis should includ e ca-rotid -cavernous fistulae, orb ital sub p eriostal ab cess, o rb it al ro o f fract u res, fro n t al m u co cele, sin u sit es, co m p licat io n o f o rb it al an d sin u s su rg ery, t u m o rs (rhab d om yosarcom a, leukem ia, lym p hangiom a) and coag ulop athies. Most of these d iseases can b e exclu-d eexclu-d b aseexclu-d o n t h e h ist o ry, p h ysical an exclu-d raexclu-d io lo g ical exam in at io n . Ch ro n ic h em at ic in t rao rb it al cyst s m ay resu lt fro m u n d iag n o sed o r u n t reat ed in t rao rb it al h em ato m as1-5.
The suggested m echanism of subperiosteal orbital h em at o m as is b leed in g fro m su b g aleal vessels, t h at enlarg es and d issects the sub g aleal sp ace, extend ing to the orbita. A fracture of the orbital roof can dissect t h e p erio rb it a an d m ake ro o m fo r b lo o d t o co lect . In o u r case, o n e o rb it al ro o f w as fract u red , b u t n o t the other, and w e could only sup p ose that the b lood d issect ed t h e su b p erio st eal sp ace co m in g fro m t h e fro n t al su b g aleal sp ace3. Co n cern in g it s cau se, t h e su b p erio st al h em at o m as can b e d ivid ed in fo u r cat eg o ries: cat rau m acat ic, co n g escat ive, syscat em ic an d sp o n -t a n eo u s. As a lrea d y m en -t io n ed , -t h ey o ccu r m o s-t often after traum a. Traum atic lesions m ay result from d irect in ju ries to th e o rb it o r its n eig h b o u rh o o d , an d m ay also b e secu n d ary t o t h o racic t rau m a, t h at re-su lts in in creased ven o u s p resre-su re in th e ju g u lar vein an d o rb it al vein s. Min o r h ead t rau m a is also relat ed to sub p eriosteal orb ital hem atom as.Cong estive etio-lo g ies in clu d e w eig h t lift in g , scu b a d ivin g an d st re-n u o u s exercise. Sire-n u sit is, co ag u lo p h at ies, co m p lica-t io n s o f o p h lica-t alm o lo g ic p ro ced u res, sin u s o r cran ial su rg ery, an d even lab o r are relat ed am o n g t h e sys-t em ic cau ses. Sp o n sys-t an eo u s in sys-t rao rb isys-t al h em asys-t o m as w it h o u t an y p red isp o sin g fact o r are very rare6-11.
Wh en t h e h em at o m a p resen t s as d ip lo p ia, p ro p -t o sis o r o -t h er sym p -t o n s an d sig n s, w i-t h o u -t lo ss o f visual acuity or signs of elevated intraocular p ressure, som e authorities ad vocate a trial of conservative m a-nagem ent, ranging from observation alone to topical u se o f t im o lo l m aleat e an d in t raven o u s o r o ral car-b o n ic a n h yd ra se in h icar-b it o rs (a ce t a zo la m id e ). Th e q u est io n o f h o w lo n g o n e sh o u ld o b serve a p at ien t w h o is co m p lain in g o f o n ly d ip lo p ia an d p ro p t o sis is still unanswered. The subperiostal intraorbital com
-p art m en t is a relat ively avascu lar s-p ace, an d it m ay t ake w eeks fo r t h e h em at o m a t o b e ab so rb ed . If t h ere is an y sig n o f in creased in t rao cu lar p ressu re o r d ecreased visu al acu it y, im ed iat e evacu at io n o f t h e h em at o m a is in d icat ed . Th is can b e acco m p lish ed throught ned d le asp iration or orb ital exp loration and d rain ag e. Ned d le asp irat io n is less t ech n ically d e-m an d in g , b u t h as t h e d isad van t ag es o f p o ssib le re-b leed in g a n d o f n o t a llo w in g rem o va l o f clo t t ed b lood . With orb ital exp loration, the surgeon can stop any active b leed ing, red uce p ossib le orb ital roof frac-tures, rem ove coag ulated b lood and to leave a d rain, if n ecessary. We ch o o se t o ap p ro ach t h e h em at o -m as w it h cran io t o -m ies in st ead y o f u sin g an y o f t h e orb ital ap p roachs, ob viously b ecause w e w ere m uch m o re co m fo rt ab le in p erfo rm in g a cran io t o m y t h an an y o t h er facial o r o rb it al ap p ro ach , b u t o t h er ap -p ro ach es t o t h e o rb it , su ch as a lat eral cran io t o m y, can also b e u sed su ccessfu lly1,2,3.
Th e u n favo rab le o u t co m e o f o u r p at ien t , w it h blindness (at least up to the last follow-up visit), stres-ses t h e n ecessit y o f b ein g aw are t o t h is u n co m m o m but dangerous com plication of head traum a, to m ake an early d iag n o sis an d in st it u t e t h e effect ive t reat -m en t , en h an cin g t h e ch an ces o f visu al p reservat io n .
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