A mysterious post-traumatic pulsatile exophthalmos

Excerpt

A 38-year-old man was injured in a motorcycle accident. He was found in a comatose state with bilateral mydriasis. The initial cerebral CT scan showed a right subdural frontal hematoma, multiple cerebral contusions and multiple fractures of the anterior skull including a fracture of the left orbital roof. Forty-eight hours later, a left pulsatile exophthalmos was noticed with vessel dilation forming a “caput medusae” (head of Medusa) shape. A cerebral angiography ruled out a carotid-cavernous fistula, and a cerebral CT scan showed a left encephalocele through the orbital roof fracture directly pushing on a bone fragment just behind the left ocular globe (Fig. 1). No surgery was undertaken. The intracranial hypertension secondary to the cerebral edema was responsible for this hernia and explained the pulsatile aspect of the exophthalmos. After a few days on neuroprotective therapy, the cerebral edema resolved, and the pulsatile exophthalmos disappeared. The patient was discharged from the intensive care unit at day 60. Encephalocele is a rare complication of head trauma and is an alternative diagnosis to carotid-cavernous fistula when a post-traumatic pulsatile exophthalmos is observed.

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