Interdisciplinary Management of Minimally Displaced Orbital Roof Fractures: Delayed Pulsatile Exophthalmos and Orbital Encephalocele

Abstract

Traumatic orbital roof fractures are rare and are managed nonoperatively in most cases. They are typically associated with severe mechanisms of injury and may be associated with significant neurologic or ophthalmologic compromise including traumatic brain injury and vision loss. Rarely, traumatic encephalocele or pulsatile exophthalmos may be present at the time of injury or develop in delayed fashion, necessitating close observation of these patients. In this article, we describe two patients with minimally displaced blow-in type orbital roof fractures that were later complicated by orbital encephalocele and pulsatile exophthalmos, prompting urgent surgical intervention. We also suggest a management algorithm for adult patients with orbital roof fractures, emphasizing careful observation and interdisciplinary management involving plastic surgery, neurosurgery, and ophthalmology.

Pulsatile Proptosis due to Intraorbital Meningocele

“…Even in orbital roof fractures, pulsatile proptosis is rare (2, 3). Our patient had only a meningocele into the left orbital due to a bony defect of the orbital roof, but no history of any of the other options mentioned above.…”

“…The differential diagnosis of pulsatile proptosis includes orbital roof fractures, encephalo- or meningoceles, neurosurgical procedures ( 1 – 3 ), neurofibromatosis type 1, and vascular malformations such as carotid-cavernous fistula and arteriovenous malformations ( 4 , 5 ). Even in orbital roof fractures, pulsatile proptosis is rare ( 2 , 3 ). Our patient had only a meningocele into the left orbital due to a bony defect of the orbital roof, but no history of any of the other options mentioned above.…”

Orbital meningocele in two case studies

“…For congenital meningoceles, the best treatment is for excision and/ligation of the cyst plus closure of the defect. [2,4] Large defects can typically be closed by reconstructing the orbital roof with titanium plates and microscrews; when these are not available, bone graft may be utilized. [4,6,8] To address persistent postoperative CSF leaks, repeated lumbar punctures may be performed if lumbar drains are not available.…”

“…[8] Longterm outcomes would likely have been improved had both patients undergone earlier surgery. [3,4,6,8]…”

“…Primitive orbital meningocele is a rare congenital malformation defined as a herniation of the meninges into the orbit through a congenital or traumatic defect in the orbital bone. [4,6] Here, we present two cases of orbital meningocele representing these two different etiologies. subarachnoid space, and (3) a chronic right low-density subdural hematoma [ Figure 2].…”