British Journal of Ophthalmology 1993; 77: 179-180 CASE REPORTS .9W,~ 179 Proptosis as a presenting sign of extradural haematoma C R Stewart, J F Salmon, Z Domingo, A D N Murray Department of Ophthalmology C R Stewart J F Salmon A D N Murray Department of Neurosurgery Z Domingo University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa Correspondence to: Dr C R Stewart, Department of Ophthalmology, Medical School, University of Cape Town, Observatory 7925, Cape Town, South Africa. Accepted for publication 3 November 1992 Abstract A conscious 15-year-old boy presented with progressive proptosis and a severe headache 2 weeks after minor blunt trauma to the head. No neurological deficit was present. Computed tomography demonstrated intracranial and intraorbital cyst-like masses. At craniotomy a subacute extradural haematoma was found which communicated with an orbital subperiosteal haematoma through a shelved orbital roof fracture. The haematomas were drained and the patient made an uneventful postoperative recovery. Although rare, an extradural haemorrhage should be considered in Figure I Preoperative appearance of the patient showing any patient presenting to an ophthalmologist infratemporal displacement of the left eye. with progressive proptosis and headache following a head injury. proptosis was present (Fig 1). There was no (BrJ Ophthalmol 1993; 77: 179-180) bruit, the proptosis was not posture dependent, and no change was found with the valsalva Proptosis is a rare manifestation of extradural manoeuvre. There was marked limitation of haemorrhage. To our knowledge, this association elevation and slight limitation of depression, has been reported previously in only 10 cases and abduction, and adduction. Fundal examination no reports have appeared in the ophthalmic of the left eye revealed a hyperaemic disc, literature.lA We report a unique case where absence of spontaneous venous pulsation, and proptosis and headache were the only presenting slightly dilated and tortuous retinal veins. There features of an extradural haematoma in a were horizontal choroidal folds in the left macula. The right eye was normal. conscious 15-year-old boy. Ultrasound of the left orbit revealed a retrobulbar soft tissue mass. Skull x ray and orbital x ray showed no bony abnormality. Case report A 15-year-old boy from a rural South African Computed tomography (CT) demonstrated a village presented to the ophthalmology depart- large left-sided frontal intracranial cyst-like mass ment at Groote Schuur Hospital complaining of (Fig 2). There was midline shift with distortion left-sided proptosis and a persistent throbbing of' the falx cerebri and compression of the frontal headache. Two weeks previously he had ventricular system. In addition a cyst-like mass bumped his head during a game of football. He of similar density was noted in the posterior did not lose consciousness at any time. The superior aspect of the orbit, displacing the globe proptosis had been noticed immediately after the forward and inferiorly (Fig 2). No orbital roof trauma and had gradually increased. He had no fracture was demonstrated. Full blood count, associated nausea, vomiting, or other neuro- erythrocyte sedimentation rate, chest x ray, and ultrasound examination of the liver were normal. logical symptoms. On examination the patient was fully conscious The Echinococcus granulosa indirect haemawith a normal affect and a Glasgow coma scale* gglutination test was negative. The patient subsequently underwent a left of 15/15. He had no neck stiffness, cranial nerve palsy, or any other localising signs. His neuro- frontal craniotomy so that an excision biopsy of logical status remained unchanged throughout the intracranial 'cyst' could be performed. On his hospital stay. elevating the frontal bone a large subacute extraThe visual acuity in the right eye was 6/6 and dural haematoma was found and drained. The in the left 6/9. On the left, 8 mm of non-axial haematoma was evacuated and a shelved linear fracture of the left orbital roof was discovered. On entering the orbit an encapsulated subperiThe Glasgow coma scale is a standardised method of scoring the level of consciousness for the purpose of clinical comparison and osteal haematoma in the superior medial aspect estimation of prognosis. The higher the score the higher the level of the orbit was found to be displacing the globe of consciousness and the better the prognosis. * .... 180 Figure 2 Coronal CT scan showing intracranial and intraorbital cyst-like masses as indicated by the arrows. Stewart, Salmon, Domingo, Murray An extradural haematoma is a life-threatening condition with a mortality rate in children of up to 50%. '° Computed tomography has resulted in earlier diagnosis of extradural haematoma and consequently a better prognosis.'°0 The clinical features of an extradural haematoma are variable, but the findings of a normal neurological examination and normal mental status in the presence of an extradural haematoma is extremely rare. " Clinical features warranting the diagnosis of an extradural haematoma after head injury may develop in a period ranging from less than 1 hour to 14 days.'2 Our case was therefore atypical in presentation. In the 10 previously reported cases of extradural haematoma associated with proptosis, a subfrontal or frontal haematoma was found in eight cases.' A retrobulbar haemorrhage was reported in only two cases, both of whom had an orbital roof fracture and associated frontal or subfrontal haematoma.' In those patients without a retrobulbar haemorrhage, it has been postulated that venous stasis, subarachnoid transmission of increased intracranial pressure, and ocular motor weakness may have played a infralaterally and forward. The subperiosteal role in the pathogenesis of the proptosis. ' haematoma was evacuated. Postoperatively the In our patient, proptosis was caused by a patient made an uneventful recovery with no neurological deficit. The proptosis slowly subperiosteal haemorrhage extending from a diminished and at the last postoperative visit (3 clinically unsuspected extradural haematoma months after surgery) had returned to normal through an orbital roof fracture. This case illustrates that an extradural haemorrhage may with no residual limitation of eye movements. be the cause of a post-traumatic headache, even in the absence of neurological signs.'2 Although rare, this diagnosis should be considered in any Comment with cyst-like intraorbital and intracranial patient The differential diagnosis of cystic lesions of the 'lesions on CT scan, particularly where a history orbit and cranial cavity includes hydatid cyst (relatively common in a rural South African of head injury and progressive proptosis is setting), sinus mucocele, dermoid cyst, obtained. aneurysmal bone cyst, cholesteatoma, orbital 1 Umansky F, Pomenanz SH. Epidural haematoma and teratoma, encephalocele, and haematic cyst.'-7 unilateral exophthalmos - a review. Acta Neurochir (Wien) 1989; 99:145-7. While patients with haematic cysts of the orbit 2 Gruszkiewicz J. Ipsilateral exophthalmos in subfrontal usually present with a subperiosteal mass months epidural hematomas - report of four cases. J Neurosurg 1972; 37: 613-5. to years after blunt trauma, there has been a 3 Watts C. Exophthalmos and epidural hematoma. South MedJ report of a haematic cyst presenting within 2 1976; 69: 1539-53. B, Lomholdt Knudsen L. Frontal epidural haemaweeks post trauma.89 Haematic cysts have been 4 Bollinger toma with ipsilateral exophthalmos. Neuroradiology 1987; associated with spontaneous haemorrhage, 29:315. D, ed. Paediatric ophthalmology. Oxford: Blackwell, blood dyscrasias, vascular disease, lymph- 5 Taylor 1990:685. angiomas, and cavernous haemangiomas.7 6 Goldberg HS, Sassani JW, Parnes RE. Traumatic intraconal hematic cyst of the orbit. Arch Ophthalmol 1992;110: 378Although haematic cysts may erode through the 80. bony orbit, an association with an extradural 7 Shapiro A, Tso MOM, Putterman AM, Goldberg MF. A clinicopathologic study of hematic cysts of the orbit. Amj haematoma has not been described.69 In this Ophthalmol 1986; 102: 237-41. case, the finding of an extradural and orbital 8 Milne HL, Leone CR, Kincaid MC, Brennan MW. Chronic haematic cysts of the orbit. Ophthalmology 1987; 94: 271-7. haematoma at the time of surgery was 9 Mund ML. Subperiosteal hematic cyst of the orbit. Ophthalunexpected, particularly as the boy was conscious mology 1981; 88: 992-6. 10 Pa§aoglu A,H.Orhon C, Koc K, Selcuklu A, Akdemir H, without neurological deficit. A similar neuroUzunoglu Traumatic extradural haematomas in pediatric radiological clinical picture associated with an age group. Acta Neurochir(Wien) 1990; 106: 136-9. HS, Salo D. Epidural hematoma: an unusual extradural haematoma has been previously 11 Snyder presentation. AmJ EmergMed 1990; 8: 538-41. reported, although in that case progressive 12 Jamieson KG, Yelland JDN. Extradural haematoma - report of 167 cases. J Neurosurg 1968; 29: 13-23. depression of consciousness occurred.4