AJR 2005; 184:S2-S3
© American Roentgen Ray Society
Bilateral Supraorbital Masses After Prolonged Headlock Injury: An Unusual Manifestation of Orbital Subperiosteal Hematomas
Shannon D. Crawford and
Mahesh R. Patel
Department of Radiology, Santa Clara Valley Medical Center, 751 S. Bascom
Ave., San Jose, CA 95128.
Received December 19, 2003;
accepted after revision April 16, 2004.
Address correspondence to M. R. Patel.
Introduction
Intraorbital subperiosteal hematoma is a relatively rare entity that
has been described in the radiology and ophthalmology literature. It is
distinct radiographically from an intraconal bleed in that the subperiosteal
space is involved, displacing the conal fat. Subperiosteal hematoma occurs
most often in young men, although it has been reported in both men and women
with a range of ages. Anatomic and physiologic characteristics are thought to
contribute to the formation of subperiosteal hematoma. Various types of
injuries have been implicated in the formation of subperiosteal hematoma, with
direct trauma the most common type. We report a headlock as a cause of injury.
To our knowledge, this has not been previously reported as an inciting event.
The presentation of bilateral subperiosteal hematomas is also unique.
Case Report
A 36-year-old man presented 4 days after an assault, during which his face
and eyes were in a headlock for several minutes. The patient complained of
blurred vision for 2 days. At physical examination, the patient was noted to
have bilateral orbital ecchymoses and right subconjunctival hemorrhage.
Limited abduction of the right eye and limited superior gaze in both eyes were
observed.
Orbital CT was performed for further evaluation (Figs.
1A,
1B and
1C) and showed high density,
curvilinear material at superior orbits bilaterally with slight downward
displacement of the globes, corresponding to the clinical findings. The
intraconal fat showed normal attenuation, excluding the possibility of
intraconal bleed. No bone fracture was seen
(Fig. 1C).
Discussion
The cause of a subperiosteal hematoma may be obvious, as in this case, or
occult [1,
2]. Subperiosteal hematomas are
most often posttraumatic and may be associated with an adjacent orbital
fracture
[1-6].
Vascular congestion has also been implicated as a cause, with increased
intravascular pressure resulting in hematoma formation
[1,
4,
6]. Connective tissue disorders
may play a role in some cases through weakening of the periosteal attachment
to bone, limiting the ability of the periosteum to tamponade
[6]. Bleeding diatheses may
also contribute to hematoma formation in a normal subperiosteal anatomic space
[1,
4]. In rare cases, no causative
event or contributing factors are identified
[1].
Analysis of the orbital anatomy helps to explain the characteristic
appearance of a subperiosteal hematoma. The orbital portion of frontal bone is
the most common site of subperiosteal hematoma formation for a number of
reasons. The frontal bone contributes the greatest surface area to the orbit
[2,
5,
6]. The periosteal attachment
to the frontal bone is relatively loose
[2,
4,
5,
6], especially in younger
individuals, allowing a hematoma to dissect into a larger potential space. The
stronger periosteal attachment at sutures generally limits extension of the
hematoma beyond the frontal bone margins
[6] although continuity with
the subperiosteal space over the frontal bone may lead to dissection of scalp
hematoma into the orbit
[6].
Early diagnosis is crucial secondary to the potential for serious
neurologic sequella, including transient or permanent blindness
[4,
5]. Clinical examination can
lead to the suspicion of subperiosteal hematoma, but radiologic evaluation is
useful to confirm diagnosis, localization of the lesion, and further
evaluation of chronicity or concomitant abnormality such as bone fracture
[4]. CT is a sensitive
technique that shows high-density, nonenhancing biconvex, or curvilinear
lesions in the superior orbits (Figs.
1A and
1B). CT may be useful for
evaluating cystic degeneration of a chronic hematoma, which may lead to
neurologic injury through mass effect. CT is also useful to analyze
concomitant abnormality such as orbital wall fracture. MRI has proven useful
in evaluating hemorrhage and shows varying T1 and T2 intensity depending on
the chronicity of the hematoma
[2,
4]. On MRI, a T1 and T2
hypointense rim has been described with chronic hematomas, indicating a
fibrous cap [4]. Although not
the first choice for evaluation, an angiogram may be of some diagnostic
benefit. Inferior displacement of the ophthalmic artery has been described
[1,
2,
5]. Underlying vascular injury
causing a subperiosteal hematoma is surmised but not generally seen on
angiogram.
The appearance of a subperiosteal hematoma is unique but not pathognomonic.
The differential diagnosis includes metastasis, lymphoma, or orbital
pseudotumor. Bilateral extraocular muscle abnormalities such as those seen
with Graves' disease or orbital pseudotumors should also be included in the
differential diagnosis.
Optimal management of a subperiosteal hematoma varies
[5-7].
A conservative approach has been used in patients with proptosis but no
neurologic symptoms. With conservative treatment, the risk for hematoma can
increase or the hematoma can become organized, causing persistent symptoms.
Successful needle aspiration of thrombus has been reported and may be required
in patients with pain, neurologic symptoms or both
[2,
3,
5,
6]. However, needle aspiration
may not be adequate in patients with organized thrombus, and surgical drainage
can be necessary [2,
8]. Advantages of surgical
drainage include the ability to remove acute and organized thrombus. Also, the
frontal bone can be directly visualized for underlying disease. A disadvantage
is that the procedure is more traumatic than needle aspiration.
Orbital subperiosteal hematoma is a relatively rare entity, occurring most
often in young men. The most common cause is trauma, although vascular
congestion, underlying connective tissue disorder, or bleeding diathesis has
been implicated. We present prolonged headlock as a unique cause of bilateral
subperiosteal hematoma.
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Introduction
Case Report
