Journal of Neuro-Ophthalmology, December 1993, Volume 13, Issue 4

Ptosis and levator paralysis caused by orbital roof fractures. Three cases with subfrontal epidural hematomas.

Blows to the forehead resulted in orbital roof fractures and subfrontal epidural hemorrhage in three patients. Neurologic eye signs were limited to ipsilateral paralysis of globe and lid elevation. In the context of an ecchymotic upper lid, these findings indicate local damage to orbital muscles rather than injury to the superior division of the third nerve. Even when such patients are alert, prompt computed tomographic (CT) scanning of the head should be undertaken to rule out an enlarging epidural hematoma.

Jounull of Clinical Neuro-ophlhalmology 13(4): 225-228, 1993. Ptosis and Levator Paralysis Caused by Orbital Roof Fractures Three Cases with Subfrontal Epidural Hematomas James R. Keane, M.D. © 1993 Raven Press, Ltd., New York Blows to the forehead resulted in orbital roof fractures and subfrontal epidural hemorrhage in three patients. Neurologic eye signs were limited to ipsilateral paralysis of globe and lid elevation. In the context of an ecchy­motic upper lid, these findings indicate local damage to orbital muscles rather than injury to the superior divi­sion of the third nerve. Even when such patients are alert, prompt computed tomographic (eT) scanning of the head should be undertaken to rule out an enlarging epidural hematoma. Key Words: Orbital roof fracture-Epidural he­matoma- Ptosis--Elevator palsy. From the Department of Neurology, Los Angeles Countyl University of Southern California Medical Center Los Angeles, California, U.S.A. Address correspondence and reprint requests to Dr. James R. Keane, 1200 North State Street, Los Angeles, CA 90033, U.S.A. 225 About 12% of epidural hemorrhages occur sub­frontally (1,2). Hematomas in this location tend to be seen in younger individuals following blows to the forehead (1). Bleeding is often venous in origin and the course subacute (1). Associated orbital signs show two main patterns: (a) delayed propto­sis, with or without orbital fracture and he­matoma, and (b) roof fracture with direct injury to the superior orbital muscles from contusion or compression by bony fragments or subperiosteal hemorrhage, as in our patients. At least nine cases of frontal epidural hematoma and progressive proptosis have been reported (3). In three patients, orbital roof fracture and he­matoma ("hematic cyst") were present. In the other six cases, the cause of proptosis was uncer­tain, but usually ascribed to impairment of orbital venous outflow (4). Ptosis and elevator paresis, as seen in the fol­lowing patients with fractures of the central orbital roof, can be important clues to associated intracra­nial hemorrhage. PATIENTS All patients were seen in neuro-ophthalmologic consultation on the neurosurgery wards of the Los Angeles County/University of Southern California Medical Center during the past 7 years. Each was personally examined and photographed. Orbital fractures and intracranial hemorrhage were iden­tified by computed tomography (CT) scans. CASE REPORTS Case 1 A 46-year-old diabetic man was found uncon­scious in the street. CT scans revealed moderate 226 J. R. KEANE right frontal and subfrontal epidural hemorrhage associated with a fracture of the orbital roof (Fig. 1, left). Examination following neurosurgical evacua­tion of the hemorrhage showed bilateral "raccoon eyes" and complete ptosis and paralysis of eleva­tion of the right eye (Fig. 2). Two weeks after dis­charge, the patient rapidly became stuporous. On readmission, a large left subdural hematoma (Fig. 1, right) was discovered and removed. [In retro­spect, minimal left extra-axial blood can be seen on the initial scans (Fig. 1, left).] As he awoke during the next several days, it became apparent that his eye and lid movements had returned to normal. Case 2 Following an automobile accident, a 19-year-old woman was admitted in stupor with a left black eye. Her vision was normal, but she had nearly complete left ptosis and elevator paresis (Fig. 2, middle). CT scan revealed left frontal and orbital roof fractures and a small subfrontal epidural he­matoma that extended into the superior orbit (Fig. 3). Three weeks later, her eye signs had returned to normal. Case 3 A 20-year-old man was assaulted and struck in the right side of his forehead by a pipe. Examina­tion after admission showed mild swelling of the FIG. 2. Ptosis and limited elevation of the eye are ev­ident in (top) Case 1, (middle) Case 2, and (bottom) Case 3. FIG. 1. Case 1. Left: Transverse CT cuts show right frontal-subfrontal epidural hemorrhage and subtle left sub­dural hematoma. Right: Two weeks following removal of epidural hematoma, the left subdural hematoma has enlarged to life-threatening proportions. JClin Neuro-ophthalmol, Vol. 13, No.4, 1993 PTOSIS AND LEVATOR PARALYSIS 227 FIG. 3. Case 2: Transverse CT views illustrate left orbital roof fracture (left) is accompanied by epidural hematoma (right). right upper lid as well as severe ptosis and limited elevation (Fig. 2, bottom). A right "blow-in" or­bital roof fracture was apparent on CT scans (Fig. 4) and a small epidural hemorrhage was present. His eye signs recovered completely within 5 weeks. DISCUSSION Blows to the forehead in our three patients caused fractures of the orbital roof (floor of the anterior cranial fossa) with associated subfrontal epidural bleeding. Neurologic eye signs were lim­ited to paralysis of globe elevation and severe ip­silateral ptosis. Ecchymosis and mild swelling of the upper lid could be distinguished from associ­ated ptosis without difficulty. Patient 1 required craniotomy (twice), but epidural hemorrhages in the other two patients were managed conserva­tively. The eye signs resolved completely in 2 to 5 weeks. The signs of "blow-out" fractures of the orbital floor have been widely publicized since their char­acterization by Smith & Regan in 1957 (5). In cen­tral floor fractures, impaired elevation of the eye may be accompanied by infraorbital numbness; in­fraduction is frequently limited and a fixed, dilated pupil is occasionally present. Inexperienced clini­cians may confuse the signs of floor fractures with partial third nerve injury. Similarly, the eye signs following roof fractures may be mistakenly attrib­uted to damage to the superior division of the third nerve. Fractures of the orbital roof are much less com-mon than those involving the floor. Of 128 patients referred for surgical evaluation of orbital fractures in the prescan era, only 7 (5.5%) had roof involve­ment (6). In a more recent referral series, the roof was involved in 4 of 53 orbital fractures (7.5%) (7). Seven "blow-in" roof fractures were seen at one trauma center during a 16-month period (0.2% of all trauma patients) (8). Children appear more sus­ceptible to roof fractures than adults: A single pe­diatric hospital collected 36 such fractures (in 32 patients) in a 5-year period and found them to be more common than floor fractures (9). Most cases like ours are hidden in aggregate re­ports of "diplopia" or "restriction of eye move­ment" in association with roof fractures (10--17). Many patients, particularly children, have been too lethargic to test fully. However, at least nine patients with isolated ptosis and limitation of ele­vation have been reported (10--13). Only one of these cases had a significant epidural hematoma (11). Rarely, medial roof fractures damage the troch­lea, producing an acquired Brown's syndrome (18,19). Perhaps the most dramatic published case of orbital roof fracture involved upward her­niation of the entire globe, which appeared to lie within the frontal lobe on CT scans (20). The diagnosis of roof fracture with local muscle involvement is strongly suggested by ecchymosis of the upper lid accompanying ptosis and levator weakness. The eye signs of most small-to­moderate orbital roof fractures will resolve rapidly without surgery, as our cases and others (9,13) demonstrate. Subfrontal bleeding is commonly as- I Clin Neuro-ophthalmol, Vol. 13, No.4, 1993 228 J. R. KEANE FIG. 4. Case 3: Coronal CT scan cuts of the orbit one month after trauma show central displaced fracture impinging upon levator-superior rectus muscle com­plex. sodated and vigilance is indicated to detect the occasional patient with a life-threatening epidural hematoma. Acknowledgment: Jamshid Ahmadi, M.D., assisted with CT scan interpretation. JGin Neuro-ophthalmol, Vol. 13, No.4, 1993 REFERENCES 1. Jamieson DG, Yelland JDN. Extradural hematoma: report of 167 cases. JNeurosurg 1968;29:13-23. 2. Gruszkeiwicz J, Doron Y, Peyser E. Frontal extradural he­matomas. Surg Neurol 1976;5:122-8. 3. Stewart CR, Salmon JF, Domingo Z, Murray ADN. Propto­sis as a presenting sign of extradural haematoma. Br JOph­thalmoI1993; 77:179-180. 4. Bollinger B, Knudsen KK. Frontal epidural haematoma with ipsilateral exophthalmos. Neuroradiology 1987;29:315. 5. Smith B, Regan WF. Blowout fracture of the orbit. Am J OphthalmoI1957;44:733-73. 6. Greenwald HS Jr, Keeney AH, Shannon GM. A review of 128 patients with orbital fractures. Am JOphthalmoI1974;78: 655-64. 7. Rootman J. Diseases of the orbit: a multidisciplinary approach. Philadelphia: JP Lippincott, 1988. 8. Chirico PA, Mirvis SE, Kelman SE, Karesh JW. Orbital "blow-in" fractures: clinical and CT features. J CAT 1989; 13:1017-22. 9. Greenwald MJ, Boston D, Pensler JM, Radkowski MA. Or­bital roof fractures in childhood. Ophthalmology 1989;96: 491-597. 10. Smith RR, Blount RL. Blowout fracture of the orbital roof with pulsating exophthalmos, blepharoptosis and superior gaze paresis. Am JOphthalmoI1971;71:1052-4. 11. Flanagan JC, McLachlan DL. Shannon GM. Orbital roof fractures: neurologic and neurosurgical considerations. Ophthalmology 1980;87:325-9. 12. Ohtsuka H, Nakaoka H. Impaired upward gaze due to sub­periosteal hemorrhage of the orbital roof. Ann Plast Surg 1987;18:547-9. 13. Bolling ]P, Wesley RE. Conservative treatment of orbital roof blow-in fracture. Ann OphthalmoI1987;19:75-6. 14. McClurg FL, Swanson PJ. An orbital roof fracture causing diplopia. Arch Otolaryngol 1976;102:497-8. 15. Sullivan WG. Displaced orbital roof fractures: presentation and treatment. Plast Reconstr Surg 1991;87:657-{j1. 16. Antonyshyn 0, Gruss JS, Kassel EE. Blow-in fractures of the orbit. Plast Reconstr Surg 1989;84:10-20. 17. Penfold CN, Lang D, Evans BT. The management of orbital roof fractures. Br JOral Maxillofacial Surg 1992;30:97-103. 18. Baldwin L, Baker RS. Acquired Brown's syndrome in the patient with an orbital roof fracture. JClin Neuro-ophthalmol 1984;4:143-14. 19. Al-Qurainy lA, Dutton GN, Moos KF, Reynolds ST, Mc­Millan N. Orbital injury complicated by entrapment of the superior oblique tendon: a case report. BrJOral Maxillofacial Surg 1988;26:336-40. 20. Ma C, Nerad JA. Orbital roof fracture with ocular hernia­tion. Am JOphthalmoI1988;105:700-1. [VBheadinjury]