Pseudo-Orbital Apex Syndrome in the Acute Trauma Setting Due to Ipsilateral Dissection of Internal Carotid Artery

Abstract

Traumatic causes of orbital apex and superior orbital fissure syndrome are uncommon. The authors present the first case of a traumatic superior orbital fissure syndrome simulating orbital apex syndrome, with loss of vision from posterior ischemic optic neuropathy. A 35-year-old man was initially felt to have a right orbital apex syndrome with left craniofacial and orbital trauma. CT revealed left orbital fractures, a right superior orbital fissure fracture, a retained metallic foreign body in the right sphenoid sinus, and a right frontoparietal subdural hematoma. CT angiography showed a secondary dissection and occlusion of the right internal carotid artery from osseous erosion of the posterolateral wall of the sphenoid sinus. Internal carotid artery dissection is a possible, though rare, cause of ischemic optic neuropathy. The right pseudo-orbital apex syndrome resulted from a mechanical superior orbital fissure syndrome and posterior ischemic optic neuropathy from an internal carotid artery dissection.

Orbital Compartment Syndrome despite Significant Traumatic Expansion of the Orbital Cavity

“…Other related trauma presentations that involve combinations of proptosis, restricted motility, are syndromes such as superior orbital fissure syndrome, orbital apex syndrome, and a carotid-cavernous fistula. A literature search of superior orbital fissure syndrome and orbital apex syndrome did not reveal any reported cases, to our knowledge, associated with an orbital hemorrhage, [5][6][7][8][9][10][11][12][13] although it remains a possibility. In these two conditions, in the absence of hematoma, proptosis can be caused by reduced ocular muscle tone or superior ophthalmic vein compression causing soft-tissue edema.…”

“…Interestingly, a traumatic "pseudoorbital apex syndrome" has been described wherein the optic nerve dysfunction was attributable to ischemia from an internal carotid artery dissection rather than compression from bony injury. 13 Traumatic carotid-cavernous fistula ("red eye shunt") typically presents with a diffusely chemotic (swollen and injected) conjunctiva, pulsatile proptosis, and ophthalmoplegia (typically abducens nerve paresis, as this crosses through the cavern rather than being protected in the cavern wall such as cranial nerves III and IV, causing lateral gaze deficiency). 14 Bruits and headaches are also common 14 ; patients may describe pulse-synchronous tinnitus.…”

“…Management of these conditions typically requires steroids in the acute stage. Interestingly, a traumatic “pseudo-orbital apex syndrome” has been described wherein the optic nerve dysfunction was attributable to ischemia from an internal carotid artery dissection rather than compression from bony injury 13…”

Acute orbital apex syndrome and rhino-orbito-cerebral mucormycosis

“…Orbital apex syndrome (OAS) is an uncommon clinical presentation consisting of complete ophthalmoplegia with vision loss, involving cranial nerves II, III, IV, V 1 , and VI. 1 OAS may result from trauma, malignancy, infection, inflammation, or vascular origins. Some of these conditions, particularly among the infectious causes, can be life-threatening with delayed diagnosis and treatment.…”

A Meta-Analysis of Traumatic Orbital Apex Syndrome and the Effectiveness of Surgical and Clinical Treatments

“…In this situation, a patient with facial trauma may present with TOAS, in the absence of any clear radiographic evidence of facial fractures trapping the cranial nerves, likely related to compression of these structures by swelling of the retro-bulbar soft tissue or a small hematoma. In practice, each case of TOAS likely has both direct and indirect mechanisms at play 2–25 . Traumatic orbital apex syndrome can result both from primary trauma and iatrogenic trauma as well 26–28 …”