Case Report

Traumatic subfrontal extradural hematoma presenting with proptosis^?

Abstract

We describe a case of a female child who presented with right-sided proptosis and pain, in which here eye as her sole complain 3 days after she had injury to her head. On investigation, she was found to have ipsilateral subfrontal extradural hematoma, which was not suspected clinically. Only 5 such cases have been mentioned, and thus, pathogenesis is not understood. This case is discussed along with possible mechanism of this extremely infrequent phenomenon.

Proptosis is an extremely rare accompaniment of frontal or subfrontal extradural hematoma (EDH), with only less than 10 cases reported in the last 20 years [1-7]. A case of frontal or subfrontal EDH manifesting with only proptosis and without any neurologic signs is even a rarer occurrence, with only 5 cases documented so far [1-3,8]. Etiopathogen- esis of proptosis is not yet clearly established [9,10]. We report such a case where a fully conscious 8-year-old girl presenting with unilateral proptosis was found to have a large subfrontal EDH.

An 8-year-old girl presented in the emergency department with complains of right-sided proptosis and continuous throbbing pain in the right eye. Three days back, she had a history of trauma to the head due to a fall from a 5-ft-high platform while playing. There was no history of loss of consciousness, vomiting, or any bleeding from the ear, nose or throat. Her mother noticed forward protrusion of eyeball 2 days after the injury, which had gradually increased since then. The mother also reported a decrease in vision since morning. On examination, she was fully conscious, with a normal Glasgow coma scale. She had no signs of raised intracranial tension or any other neurologic signs. Her bilateral pupils were equal and normally reacting to light. Proptosis of the right eye was present (Fig. 1), with restriction of movements. Proptosis was not posture dependent and did not change with the valsalva. There was no bruit. Fundus examination showed disk edema and

^? Conflict of interest: none.

Fig. 1 Eight-year-old girl with proptosis of the right eye.

hyperemia and macular edema, along with the absence of spontaneous venous pulsations and slightly dilated tortuous retinal veins in the right eye. Examination of the left eye was normal. Skull x-ray did not show any bony abnormality. Computed tomography of the head demonstrated a large subfrontal EDH on the right side with Midline shift to the left (Fig. 2). There was no orbital roof fracture or any other orbital lesion. She was subjected to right frontal craniotomy. postoperative course went uneventful without any neurolog- ic deficit, and proptosis regressed gradually for 4 days. After 5 months of follow-up, she has normal vision, no restriction of eye movements, and no neurologic deficit.

Extradural hematoma comprises approximately 1% of head injury cases and most frequently develops in the temporal or temporoparietal regions [11]. Acute subfrontal

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539.e6 Case Report

Fig. 2 Computerized tomography scan of the head of same patient as in Fig. 1, revealing a large right subfrontal extradural hematoma.

EDH is a rare finding [12]. Most of the cases of EDH are the result of bleeding from the epidural vessels or the draining of emissary veins [12]. Development of proptosis in a case of frontal or subfrontal EDH is rare, and only countable cases have been described in the literature. Umansky and Pomenanz

[8] in 1989 reported a series of 10 such cases. Since then, in the last 20 years, less than 10 cases have been reported [1-7]. Furthermore, clinically unsuspected frontal or subfrontal EDH presenting with only proptosis is an extremely rare phenomenon and has been reported only 5 times in the literature. Two such cases were described by Umansky and Pomenanz, in their case series 20 years back, and 3 other cases were reported afterward as single-case reports [1-3].

The cause of proptosis in EDH is not yet clearly known. Direct compression by the frontal EDH over the cavernous sinus and the superior ophthalmic vein leading to disturbed venous return from the orbit has been put forward as a possible cause [9,10]. Other possibility may be the compression of the periorbita caused by the blood extending from the frontal EDH itself through the fractured orbital roof [9]. Rarely, development of orbital subperiosteal hematoma along with frontal/subfrontal EDH may lead to the eyeball being pushed interiorly [2,3,5,8]. Among the only 3 cases reported in the last 20 years, 2 had associated orbital roof fracture as well as orbital subperiosteal hematoma [1,3],

whereas 1 had only orbital subperiosteal hematoma [2]. Both of these 2 findings were not found in the present case.

The condition is very serious because the pressure within the orbit goes on increasing until the perfusion of the eye becomes inadequate. This can lead to diminution or loss of vision if the orbit is not decompressed as early as possible [1,8].

Computed tomography scan provides a rapid diagnosis and aids in planning of surgical intervention for acute subfrontal EDH. It will also help to see orbital roof fracture and rule out orbital subperiosteal hematoma [5,13]. Prompt surgical intervention in the form of craniotomy should be planned and performed without loosing much time to avoid possible loss of vision and life [1,3,8].

In the present case, development of proptosis was attributed to the direct compression by the underlying frontal EDH over the cavernous sinus and/or the superior ophthal- mic vein causing venous stasis, as there was no orbital roof fracture or associated retro-orbital hemorrhage. Underlying EDH was never suspected on clinical grounds. Thus, this case emphasizes the possibility of proptosis being a sign of underlying posttraumatic frontal extradural hematoma, even in the absence of neurologic signs. This case also illustrates the importance of early diagnosis and surgical intervention to avoid potential loss of vision.

Although extremely rare, the diagnosis of extradural hematoma should always be considered in a patient presenting with progressive proptosis, particularly when a history of head trauma (how minor may be) is present, even in the absence of neurologic signs. The present case, along with previously reported similar cases, will definitely help the researchers to know the pathogenesis of this phenome- non, which is still not yet clear.

Shilpi Singh Gupta MS (Gen Surg) Onkar Singh MS (Gen Surg) Department of Surgery

M.G.M Medical College & M.Y. Hospital

Indore 452001, India E-mail address: [email protected]

Ankur Hastir MS (Gen Surg)

Department of Surgery

M.G.M Medical College & Hospital Navi Mumbai 410206, India

doi:10.1016/j.ajem.2009.08.011

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