Acute traumatic orbital encephalocele: A case report with review of literature
A 25-year-old man was admitted following a motor vehicle accident. Neurological examination revealed that he was unconscious with a glasgow coma scale (GCS) score of 10 [E2V3M5]. He had bilateral periorbital hematoma more on the right side. Visual acuity and extraocular muscle motility of both eyes could not be evaluated completely due to periorbital hematoma, soft tissue swelling, and reduced level of consciousness of the patient. His pupils were bilaterally equal and reactive. Cranial CT axial sections of the head revealed hematoma in the left frontal lobe causing a midline shift along with a depressed fracture of the left frontozygomatic region and a bilateral transverse fracture of the orbital roof []. He underwent surgical evacuation of left frontal contusions, elevation, and removal of depressed segments of the left frontozygomatic bone. A dural tear was also found at the depressed fracture site and duraplasty was done using a pericranial patch. Postoperatively on day 2, he developed rapid progressive proptosis and severe congestion of conjunctiva [] contralateral to the operated site. Fundoscopy was attempted but could not be performed because of periorbital edema. A repeat CT scan of the head was performed in which right frontal contusion had developed with edema []. Orbital CT coronal and axial scan was also performed which revealed the formation of an encephalocele toward the right orbit []. The right globe was displaced laterally, inferiorly, and anteriorly. The optic canal and the optic nerve were intact. The patient underwent right frontal craniotomy wherein the right orbital roof was decompressed, and dural tear and the protruding brain tissue into right orbit were identified (Housepian's approach).[] After excision of the protruding part of the brain microsurgically, the dura was reapproximated with a locked running stitch, and a water-tight closure was achieved. The orbital roof region was covered using temporalis fascia graft. The postoperative period was encouraging, and the right eye proptosis and congestion regressed rapidly [Figure –]. The patient recovered well and was discharged from the hospital on the 16th post-traumatic day when he was conscious with a GCS score of 15 and had intact vision although with mild limitation of movement in the right eye. At a follow-up after three months, cosmetic and neurological recovery was excellent []. At the last follow-up after nine months, the patient was in good health with no neurological deficits. The final visual outcome was excellent, and the patient recovered full vision and had complete range of extraocular motions in both eyes.