Subarachnoid Hemorrhage and Vasospastic Stroke After Self-Enucleation

Abstract

A 31-year-old intoxicated woman self-enucleated her left eye during an acute psychotic episode. CT revealed avulsion of the intracranial optic nerve, chiasmal edema, and adjacent subarachnoid hemorrhage. Exploration via transconjunctival orbitotomy was performed, and the globe and 4.8 cm of contiguous optic nerve were removed. The patient developed postoperative contralateral visual loss followed by middle cerebral artery vasospasm and bilateral cortical infarcts.

Complications and outcomes after autoenucleation

“…In 2007, Kotlus and Lo [22] published the first account of subarachnoid hemorrhage and eventual vasospastic stroke after autoenucleation. An acutely psychotic 31-year-old female patient self-enucleated her left eye.…”

Intracranial Arterial Avulsion During Orbital Exenteration

“…Rare cases of carotid laceration and subarachnoid hemorrhage have been reported following autoenucleation. 9,10 Intracranial hemorrhage following enucleation or exenteration appears to be an exceedingly rare event. Only one case of subarachnoid hemorrhage in the temporoparietal region following enucleation has been published and in this case, the authors concluded that the hemorrhage occurred secondary to an increase in blood pressure during extubation 11 ; of note, no angiography was performed to rule-out laceration.…”

Polysubstance-Induced Self-Enucleation after Motor Vehicle Collision

“…Self-enucleation (oedipism) is an exceedingly rare form of self-mutilation generally associated with severe psychiatric disorders. [1][2][3][4] We describe a case in a patient with no psychiatric history that sustained a skull fracture in a motor vehicle crash. Toxicology studies revealed the presence of multiple substances including methamphetamines, cannabinoids, and benzodiazepines and the patient reported illicit use of the dissociative anesthetic phencyclidine.…”

“…Autoenucleation is among the rarest forms of selfmutilation, and is usually associated with chronic and severe psychiatric disorder, namely schizophrenia. [1][2][3][4] It has been associated with a first psychiatric episode, which often occurs late in the second decade of life. No association of autoenucleation with acute skull fracture has been previously described.…”

“…Others have reported complications of subarachnoid hemorrhage including vasospasm and cerebrovascular accident leading contralateral blindness. 4 Aneurysm at the junction of the ophthalmic artery and the internal ca-rotid secondary to traction, bacterial meningitis and panophthalmitis leading to contralateral blindness have also been reported. 1 We recommend considering CT angiogram of the head to investigate for intracranial bleeding or vascular injury including traction aneurysm or transection, regardless of whether or not apparent control of bleeding is achieved with external arterial ligation or orbital packing.…”