Can a forehead hematoma cause raccoon eyes?

Raccoon Eyes from Forehead Hematoma

Yes, a forehead hematoma can cause raccoon eyes as blood from the forehead injury tracks downward through fascial planes into the periorbital tissues.

Mechanism of Raccoon Eyes

Raccoon eyes (periorbital ecchymosis) occur when blood tracks into the loose connective tissue around the eyes. This can happen through several mechanisms:

1. Direct tracking of blood: When a forehead hematoma forms, gravity can cause the blood to track downward through fascial planes into the periorbital tissues.

2. Anatomical considerations: The periorbital area has loose connective tissue that easily accumulates blood. The orbital septum may limit the spread in true "raccoon eyes" from basal skull fractures, but blood from a forehead hematoma can still cause periorbital discoloration.

Clinical Significance

The appearance of raccoon eyes after head trauma requires careful evaluation because:

• While it can occur from a simple forehead hematoma, it may also indicate more serious conditions:

  • Basal skull fractures (classic cause)
  • Facial fractures
  • Convexity fractures

• Timing: Raccoon eyes typically develop hours to days after the initial trauma as blood gradually tracks downward.

Differential Diagnosis

It's important to distinguish raccoon eyes from a forehead hematoma from other causes:

1. Traumatic causes:

   • Basal skull fracture (true "raccoon eyes" with tarsal sparing)
   • Direct periorbital trauma
   • Birth trauma in neonates 1

2. Non-traumatic causes:

   • Amyloidosis 2
   • Neuroblastoma (especially in children) 3, 4
   • Blood disorders (leukemia, multiple myeloma) 3
   • Vascular disorders
   • Severe vomiting 5

Evaluation

When raccoon eyes develop after a forehead injury:

1. History:

   • Mechanism of injury
   • Time course of raccoon eyes development
   • Associated symptoms (headache, vision changes, nausea)

2. Physical examination:

   • Assess for other signs of skull base fracture:
     • CSF rhinorrhea or otorrhea
     • Battle's sign (mastoid ecchymosis)
     • Hemotympanum
   • Neurological examination
   • Vision assessment

3. Imaging:

   • Consider CT scan if there are concerning features suggesting skull fracture or intracranial injury

Management

Management depends on the underlying cause:

1. Simple forehead hematoma with tracking:

   • Observation
   • Cold compresses
   • Elevation of the head
   • Pain control

2. If signs of more serious injury:

   • Neurosurgical consultation
   • Appropriate imaging
   • Hospital observation

Key Points

• Raccoon eyes can develop from a simple forehead hematoma as blood tracks downward.
• The presence of raccoon eyes should prompt evaluation for more serious injuries, especially in the absence of direct periorbital trauma.
• In children, non-traumatic causes like neuroblastoma should be considered when raccoon eyes appear without adequate trauma history 4.
• True "raccoon eyes" with tarsal sparing are more specific for basal skull fractures 5.
• Raccoon eyes typically resolve over 1-2 weeks as the blood is reabsorbed.