What is the appropriate management of raccoon eyes (bilateral periorbital ecchymosis) indicating a basal skull fracture in a patient involved in a pedestrian or vehicular collision?

Management of Raccoon Eyes Secondary to Pedestrian vs Vehicular Accident

Immediately obtain CT imaging of the orbits without contrast and CT head to evaluate for basal skull fracture, intracranial injury, and associated facial trauma, while simultaneously stabilizing hemodynamics and preventing secondary brain injury. 1, 2

Immediate Resuscitation and Prevention of Secondary Brain Injury

The presence of raccoon eyes (periorbital ecchymosis) in a trauma patient mandates aggressive management of systemic factors that worsen outcomes:

• Maintain mean arterial pressure ≥ 80 mmHg to prevent secondary cerebral insults, as hypotension (systolic BP < 90 mmHg) for even 5 minutes increases neurological morbidity and mortality significantly. 1

• Prevent hypoxemia (maintain SaO2 > 90%), as the combination of hypotension and hypoxemia carries a 75% mortality rate in traumatic brain injury. 1

• Assess Glasgow Coma Scale immediately to determine injury severity and guide subsequent management decisions. 1

Mandatory Imaging Protocol

CT imaging is non-negotiable regardless of clinical presentation, as clinical signs alone have poor diagnostic performance (specificity 52.8%, positive predictive value 25.7% for basal skull fracture). 3

Primary Imaging Studies:

• CT orbits without contrast is the most accurate modality with 94.9% sensitivity for detecting orbital fractures, soft tissue injuries, hemorrhage, and foreign bodies. 3, 2

• CT maxillofacial provides comprehensive evaluation of skull base and facial bone integrity with high-resolution delineation of osseous and soft-tissue structures. 3, 2, 4

• CT head is complementary and mandatory, as 68% of facial fracture patients have associated intracranial injury, and one-third of frontal sinus fractures have concomitant intracranial pathology. 1, 3

• Thin-section orbital CT with multiplanar reconstructions is superior for identifying integrity of the osseous orbit and skull base. 2

Imaging Indications Based on GCS:

• Severe TBI (GCS ≤ 8) or moderate TBI (GCS 9-13): Brain and cervical CT scans should be performed systematically and without delay. 1

• Mild TBI (GCS 14-15) with periorbital hematoma: CT scan is mandatory as this is a sign of basal skull fracture. 1

Critical Life-Threatening Complications to Exclude Immediately

Oculocardiac Reflex:

• Monitor for bradycardia or heart block, which indicates extraocular muscle entrapment causing oculocardiac reflex—this is a potentially life-threatening condition requiring urgent surgical intervention. 2

Globe Injury:

• Assess for globe rupture or laceration, which occurs in up to 24% of orbital fractures and must be excluded immediately before any manipulation. 2

Traumatic Optic Neuropathy:

• Evaluate for visual loss or visual field defects, which indicate direct or indirect injury to the optic nerve requiring specialized management. 1, 2

CSF Leak:

• Assess for rhinorrhea, otorrhea, or hemotympanum, though these classic signs of basal skull fracture are rarely present alongside periorbital ecchymosis (observed in only 3, and 7 patients respectively out of 36 in one series). 5

Associated Injury Patterns

Raccoon eyes can indicate multiple injury patterns beyond basal skull fracture:

• Basal skull fractures (42% of cases with periorbital ecchymosis). 5

• Soft tissue injuries without fractures (25% of cases). 5

• Convexity skull fractures (22% of cases). 5

• Facial fractures (8% of cases). 5

• Cranial nerve injury is the most common clinical feature associated with periorbital ecchymosis (observed in 28% of patients). 5

Monitoring and Repeat Imaging

• Obtain repeat CT scan if there is secondary neurological deterioration or a decrease of at least 2 points in Glasgow Coma Scale. 1

• Consider transcranial Doppler to assess cerebral perfusion, particularly if diastolic velocity < 20-25 cm/s or pulsatility index > 1.25-1.4, which predict poor outcomes and secondary neurological degradation. 1

Common Pitfalls to Avoid

• Do not assume periorbital ecchymosis always indicates basal skull fracture—only 42% of cases in trauma series actually have basal skull fractures, while 25% have only soft tissue injury. 5

• Do not delay imaging waiting for other "classic signs" of basal skull fracture to appear—these signs are rarely present together with periorbital ecchymosis. 5

• Do not perform MRI as initial imaging—CT is faster, more readily available in trauma settings, and superior for detecting acute fractures and hemorrhage. 3, 2

• Do not miss muscle entrapment in "trap door" fractures—these can rapidly cause ischemic injury to extraocular muscles and present with oculocardiac reflex requiring urgent surgery. 1, 2