Frontal and orbital bone infarctions causing periorbital swelling in patients with sickle cell anemia

A review of spontaneous intracranial extradural hematoma in sickle-cell disease

Sickle-cell disease is common among patients of Afro-Caribbean origin. Though it can precipitate neurological conditions, it only rarely causes neurosurgical problems, with very few reported cases. We describe the case of a 7-year-old girl with a background of sickle-cell disease (SCD) brought into an acute neurosurgical unit in extremis, signs of a raised ICP, and with no history of recent trauma. Following further investigations, an acute drop in the hemoglobin and hematocrit levels were noted, with the cause of her presentation being attributed to a sickling crisis causing skull convexity infarction and resulting in spontaneous bilateral extradural hematomas requiring emergency evacuation. We review the current literature and propose the pathophysiological mechanism behind this phenomenon.

Orbital compression syndrome in sickle cell disease

PURPOSE

To present 3 cases of orbital compression syndrome caused by infarction of the greater wing of the sphenoid in patients with sickle cell disease.

METHODS

Case report and review of the literature.

RESULTS

Three patients with sickle cell disease (2 males aged 22 and 16 years, and a 10-year-old girl) who presented with proptosis, limited ocular motility, and chemosis were found to have an infarction of the marrow space of the greater wing of the sphenoid that produced an orbital subperiosteal hemorrhage and exudate demonstrated on MRI. Two patients suffered compressive optic neuropathy; both patients recovered normal optic nerve function. Orbital edema resolved within 48 hours of receiving 1 g methylprednosolone daily. The third patient had normal optic nerve function and his orbital edema improved with methylprednisolone 250 mg/day and intravenous Kefzol over 3 days. In the literature, there are 27 similar cases; 5 were treated surgically and the remainder were managed medically.

CONCLUSIONS

Patients with sickle cell disease are at risk for orbital compression syndrome secondary to orbital bone infarction, in the setting of vaso-occlusive crises. This diagnosis should be considered when a patient with sickle cell disease presents with headache, proptosis, decreased motility, and/or optic nerve compromise.

Orbital involvement in sickle cell disease: a report of five cases and review literature

PURPOSE

To present five cases of orbital infarction in sickle cell disease and review relevant literature.

METHOD

We reviewed the hospital records of 5 patients with sickle cell disease who developed a periorbital swelling during a vaso-occlusive crisis and were managed at our hospital between April 1992 and June 2000.

RESULTS

The 5 patients (4 with homozygous sickle cell disease and 1 with sickle cell-beta-thalassaemia disease) were aged 6-15 years with a history of multiple admissions for vaso-occlusive crises. The periorbital swelling spread to the orbit in 4 cases and resulted in proptosis (2 cases), restriction of ocular motility and visual impairment. In all 4 cases, computed tomography and/or magnetic resonance imaging of the orbits showed a mass adjacent to the orbital wall. In 2 cases the mass was identified as a haematoma. Orbital wall infarction was demonstrated in 3 cases by bone/bone marrow scintigraphy. Epidural haematomas were detected by computed tomography in one case. All patients received intravenous fluids, analgesics, broad spectrum antibiotics and steroids, as well as simple or exchange transfusion, and responded well to medical management.

CONCLUSIONS

Infarction of orbital bones during vaso-occlusive crises in sickle cell disease presents acutely with a rapidly progressive periorbital swelling. Haematomas frequently complicate the condition and, along with the inflammatory swelling, may lead to orbital compression syndrome. The condition is therefore sight-threatening, and necessitates prompt diagnosis and appropriate management for resolution without adverse sequelae. Imaging techniques are invaluable in the evaluation of patients. The majority of cases resolve with conservative treatment that includes steps to combat the vaso-occlusive crisis and use of systemic steroids under antibiotic cover.

Orbital compression syndrome in sickle cell disease

BACKGROUND

Orbital complications are an uncommonly reported finding in sickle cell disease.

METHODS

The authors review the reported orbital manifestations of sickle cell disease and discuss a patient with hemoglobin sickle beta(0) thalassemia in whom rapidly progressive bilateral orbital compression developed.

RESULTS

Computed tomography of the orbits in a patient with fever, headache, orbital swelling, and optic nerve dysfunction displayed bilateral superior subperiosteal cystic masses. Surgical exploration showed bilateral liquefied hematomas, which were evacuated. Recovery was complete 13 days after surgery. A mild recurrence 14 months later resolved with conservative treatment. The literature contains 11 reports of 16 young patients with sickle cell disease (15 sickle cell disease [Hb SS] and 1 hemoglobin sickle cell disease [Hb SC]) with rapidly developing findings ranging from frontal headache, fever, and eyelid edema to bilateral complete orbital compression syndrome. Including our patient, 60% had orbital hemorrhage on computed tomography. Ten of 12 patients tested were found to have orbital bone marrow infarctions. Sixteen of 17 patients had complete recovery; 13 were treated conservatively and 4 surgically. Only 2 of 17 had recurrence.

CONCLUSIONS

Orbital complications in sickle cell disease are unusual manifestations in which a vaso-occlusive process in the marrow space around the orbit results in frontal headache, fever, eyelid edema, and often orbital compression syndrome. Subperiosteal hematomas are common and appear to result from bone marrow infarctions. Appropriate management requires a thorough evaluation to exclude other hemorrhagic, infectious or neoplastic processes, as well as vigilant ophthalmic monitoring. Supportive care is effective, unless optic nerve dysfunction or large hematomas are present, which would indicate that surgical evacuation is warranted to prevent loss of vision and to speed recovery.

Skull infarction and epidural hematomas in a patient with sickle cell anemia

PURPOSE

Epidural hematomas are unusual manifestations of sickling disorders. We report a patient with sickle cell anemia and multiple skull infarctions associated with epidural hematomas. The association of skull infarctions and epidural hematomas in sickling hemoglobinopathies is reviewed.

PATIENTS AND METHODS

A 14-year-old boy with hemoglobin SS presented with lower back pain, left hip pain, headache, and fever. A bone scan was used to evaluate the patient for possible osteomyelitis. Head computed tomography (CT) and magnetic resonance imaging (MRI) were employed to delineate intracranial pathology.

RESULTS

The bone scan showed multiple areas of decreased uptake in the skull consistent with acute infarction before abnormalities were present on physical examination. CT scan showed a bony contour deformity of the right frontal bone, suggestive of infarction. A right frontal extra-axial collection of blood was also observed below the bony abnormality. MRI further delineated bilateral frontal and left parietal collections adjacent to the bony abnormalities consistent with subacute epidural hematomas.

CONCLUSIONS

This case emphasizes the need to recognize skull infarctions and epidural hematomas as rare but potential complications of sickle cell disease. The diagnosis was facilitated by MRI, which has not been used in previous cases of skull infarctions. Moreover, our patient was successfully managed without surgical intervention.

Orbital complications of sickle cell disease

Swelling and pain of the peri-orbital tissues in patients with sickle cell disease has been described. This has most often been ascribed to orbital apex syndrome, but there are recent reports in the literature of frontal bone infarctions compounding this syndrome. We will present a case report of a child with sickle cell disease with bilateral orbital abscesses and frontal bone infarctions. The literature pertaining to the diagnosis and treatment of the orbital complications of sickle cell disease is reviewed. We stress that intravenous antibiotics are not adequate therapy for orbital abscesses and that these must be drained surgically.

Sickle-cell anemia--a review

Sickle-cell anemia is a common disease, affecting more than 50,000 blacks in the United States. Since 1970 the morbidity and mortality have improved, with patients surviving well into their fourth decade. This article discusses the spectrum of serious complications of sickle-cell anemia. Crises and complications that result from the sickling process are presented with recommendations for emergency department evaluation and management. The painful bone crisis and pain control are also discussed.

Proptosis, skull infarction, and retro-orbital and epidural hematomas in a child with sickle cell disease

A Saudi child with homozygous sickle cell disease (SS) presented with bilateral periorbital swelling, right-sided proptosis, skull bone infarcts, and retro-orbital and epidural hematomas. The findings of skull bone infarcts, retro-orbital and epidural hematomas are rare in patients with sickle cell disease.