From the Guidelines
For a head injury with ecchymosis around the eyes (raccoon eyes), a non-contrast CT scan of the head is the recommended initial imaging study. This type of CT scan is preferred because it can quickly detect acute hemorrhage, fractures (particularly basilar skull fractures which often cause raccoon eyes), brain contusions, and other traumatic brain injuries without requiring intravenous contrast. The presence of periorbital ecchymosis suggests a possible basilar skull fracture, specifically involving the anterior cranial fossa, as blood tracks from the fracture site into the periorbital tissues.
Key Points to Consider
- The American College of Radiology (ACR) recommends non-contrast head CT for the initial imaging of patients with acute head trauma, especially when there are signs of basilar skull fracture, such as raccoon eyes 1.
- Non-contrast CT is sensitive for the detection of clinically important traumatic brain injuries, including intracranial hemorrhage, extra-axial fluid collections, skull fractures, and radiopaque foreign bodies 1.
- Clinical decision rules, such as the New Orleans Criteria and the Canadian CT Head Rule, can help guide the decision to perform a CT scan in patients with mild head trauma, but these rules may not apply in cases with obvious signs of significant injury, such as raccoon eyes 1.
Additional Imaging Considerations
- In some cases, additional imaging may be needed based on initial findings, such as CT angiography if vascular injury is suspected or MRI for better evaluation of brain parenchyma.
- The scan should be performed urgently as raccoon eyes in the setting of head trauma represent a concerning sign that may indicate significant underlying injury requiring prompt diagnosis and management.
From the Research
Head Injury with Ecchymosis around Eyes
- A head injury with ecchymosis around the eyes may require a noncontrast head CT scan as the initial examination, as stated in the study 2.
- Noncontrast CT of the head is a widely used noninvasive investigation for acute and chronic neurological conditions, including head trauma, according to the study 3.
- The CT scan can help detect subtle vascular changes, parenchymal and bony changes, and identify vascular pathologies, as mentioned in the study 3.
- In cases of suspected intracranial vascular injury, CT angiography or venography, or MR angiography or venography, may be the most appropriate imaging study, as recommended in the study 2.
CT Scan Types
- Noncontrast head CT is the most appropriate initial examination in patients with minor or mild acute closed head injury, as well as patients with moderate to severe acute closed head injury, according to the study 2.
- CT scanning is the current first imaging technique to be used after head injury, and the first scan is usually done without contrast enhancement, as stated in the study 4.
- Noncontrast computed tomography (CT) provides important diagnostic information for patients with traumatic brain injury, and a systematic approach to image interpretation optimizes detection of pathologic air, fractures, hemorrhagic lesions, brain parenchymal injury, and abnormal cerebrospinal fluid spaces, as mentioned in the study 5.
Imaging Interpretation
- A systematic approach to image interpretation optimizes detection of pathologic air, fractures, hemorrhagic lesions, brain parenchymal injury, and abnormal cerebrospinal fluid spaces, as discussed in the study 5.
- Bone and brain windows should be reviewed to enhance injury detection, and findings of midline shift and mass effect should be noted, as recommended in the study 5.
- The study 6 provides a structure for reading a CT head scan, to help identify key findings that may warrant further specialist neurosurgical or stroke team referral.