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Orbital and Subcutaneous Encephalocele 10 Days Following an Orbital Roof Fracture in a Child

Arfeen, Shaimaa A. M.D., Ph.D.*; Elnahry, Ayman G. M.D., M.Sc.*; Albadawi, Maha A. M.D.*; Gamal El-Din, Dina H. M.D., Ph.D.

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Ophthalmic Plastic and Reconstructive Surgery: May/June 2020 - Volume 36 - Issue 3 - p e79
doi: 10.1097/IOP.0000000000001431
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An 18-month-old boy admitted at the neurosurgery department following a fall developed sudden swelling of his left upper eyelid 10 days later. Initial evaluation at presentation revealed a fissure fracture on the left lateral aspect of his frontal bone continuous with a left orbital roof fracture. Ophthalmologic examination at that time showed only mild eyelid ecchymosis. On examination in the second consult, there was marked swelling of the left upper eyelid with inability to open the eye (Fig. A). CT scan revealed widening of the frontal bone fracture and the left orbital roof fracture with a hypodense cystic swelling in the left orbit and upper eyelid and left frontal lobe contusion. A three-dimensional CT reconstruction demonstrated the extent and shape of the skull fracture (Fig. B). MRI showed a hyperintense cystic swelling on T2-weighted imaging communicating with the cranial cavity with some isointense solid components (Fig. C,D). The patient was diagnosed with a left orbital and subcutaneous encephalocele and scheduled for emergency repair surgery. Intraoperatively, excision of herniated contused brain tissue was performed together with bone and dura repair. One week postoperatively, there was marked improvement of the condition (Fig. E,F)

Clinical and imaging findings at presentation (A-D) and following repair (E and F). Ten days following trauma, there was sudden swelling of the patient’s left upper eyelid (A). Three-dimensional CT reconstruction best demonstrated the extent of the fracture (B). MRI showed a hyperintense cystic swelling on T2-weighted imaging seen in the orbit and upper eyelid in coronal (C) and sagittal (D) sections consistent with an orbital and subcutaneous encephalocele. Postoperatively there was marked improvement in clinical (E) and MRI (F) findings.

Orbital encephalocele is a rare complication of orbital roof fracture which is also rare but more common in children. It may be delayed, owing to brain herniation from increased intracranial tension and commonly associated with frontal lobe contusions. It is best visualized using MRI and requires immediate intervention.

© 2020 The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc.