What are the next steps for a 10-year-old girl who experienced head trauma from a bicycle accident, with no initial head wound, but developed facial swelling and periorbital (around the eyes) edema the next morning?

Immediate CT Head Without Contrast is Mandatory

This 10-year-old girl with delayed facial swelling and periorbital edema following head trauma requires immediate non-contrast CT head imaging to evaluate for basilar skull fracture, which is the most concerning diagnosis given her presentation. 1, 2

Why This Presentation is High-Risk

Periorbital ecchymosis and facial swelling developing the morning after head trauma are classic signs of basilar skull fracture, even when no external head wound is visible. 3 This clinical finding places her in the "high-risk" category regardless of her Glasgow Coma Scale score, mandating immediate CT imaging and hospital admission. 1, 2

Key Clinical Features to Assess Immediately:

• Mental status changes or altered consciousness (any GCS <15 is high-risk) 1
• Other basilar skull fracture signs: Battle's sign (mastoid ecchymosis), hemotympanum, CSF otorrhea/rhinorrhea, though these are rarely present together with periorbital ecchymosis 3
• Cranial nerve deficits (most common associated finding with periorbital ecchymosis in trauma) 3
• Visual changes or diplopia (suggests orbital injury or optic nerve involvement) 1
• Palpable skull fractures 1

Immediate Imaging Protocol

CT head without IV contrast using pediatric protocols is the first-line imaging study. 1 The scan must include:

• Bone windows with double fenestration to fully characterize any basilar skull fracture 2
• Multiplanar and 3D reconstructions to increase sensitivity for fractures and small hemorrhages 1
• Thin-section orbital CT with multiplanar reconstructions if orbital injury is suspected based on visual symptoms or extraocular movement restriction 1

CT angiography of supra-aortic and intracranial vessels should be performed because basilar skull fractures are a specific risk factor for traumatic arterial dissection. 2, 4 This is critical and often missed.

Why Delayed Swelling Matters

Periorbital edema developing hours after trauma can indicate:

• Basilar skull fracture (most concerning) 3, 5
• Orbital roof fracture with CSF leak (rare but documented, presents as progressive eyelid swelling) 5
• Orbital fractures (orbital roof fractures are most common in children <8 years old; orbital floor fractures in older children) 1
• Intracranial hemorrhage tracking into periorbital tissues 3

The absence of immediate swelling does not exclude serious injury—blood tracking along tissue planes into periorbital tissues takes time to manifest. 3

Management Algorithm

Step 1: Immediate Actions

• Maintain systolic blood pressure >110 mmHg at all times (even single episodes of hypotension markedly increase mortality in head trauma) 2, 4
• Obtain CT head without contrast immediately 1, 2
• Request neurosurgical consultation if CT shows intracranial hemorrhage, significant fractures, or mass effect 2, 4

Step 2: Risk Stratification Based on CT Results

If basilar skull fracture is confirmed:

• Admit for close neurological observation with serial examinations 2, 4
• Obtain CT angiography to evaluate for vascular injury/dissection 2, 4
• Repeat CT at 6-12 hours if initial scan shows associated intracranial injury 2
• Monitor for delayed complications including vascular dissection, meningitis, and cranial nerve injury 2, 3

If orbital fracture without basilar involvement:

• Assess for extraocular muscle entrapment (trap door fractures are common in children due to elastic bone) 1
• Evaluate for globe injury if visual changes present 1
• Consider urgent ophthalmology consultation if vision loss, diplopia, or restricted eye movements 1

Step 3: Admission Criteria

Do not discharge this patient without adequate observation, even if GCS is 15 and CT appears reassuring initially. 2, 4 Signs of basilar skull fracture mandate admission regardless of initial neurological status. 2

Critical Pitfalls to Avoid

• Do not assume "no head wound" means no serious injury—basilar skull fractures and intracranial hemorrhage frequently occur without external wounds 3, 5
• Do not miss vascular injuries—always obtain CT angiography given the high-risk nature of basilar skull fractures for arterial dissection 2, 4
• Do not wait for other classic signs (Battle's sign, hemotympanum, CSF leak) before imaging—these are rarely present together with periorbital ecchymosis 3
• Do not discharge without imaging—periorbital ecchymosis after head trauma is never a benign finding in isolation 3, 5
• Do not use MRI as initial imaging—it is too slow in the acute trauma setting and less sensitive for fractures 1

Alternative Diagnoses to Consider (After Excluding Fracture)

If CT is negative for fracture and intracranial injury, consider:

• Soft tissue injury without fracture (occurs in 25% of cases with periorbital ecchymosis) 3
• Orbital CSF leak without obvious fracture (rare but documented on MRI when CT appears normal) 5

However, imaging must be obtained first before attributing symptoms to benign causes. 1, 2