Ventriculo-orbital fistula in closed head injury Case report HIDEO TERAO, M.D., AND SE|TARO SATO, M.D. Neurosurgical Service, Tokyo Municipal Hiroo Hospital, Tokyo, Japan ~" A ventriculo-orbital fistula developing as a result of closed head injury produced intraorbital compression symptoms including downward deviation of the globe and inability of upward gaze. Percutaneous injection of Conray clearly demonstrated the fistula, which was successfully closed by frontal craniotomy. KEYWoRDs head injury

9 ventricular fistula 9 Conray ventriculography 9 cerebrospinal fluid l e a k a g e 9 orbital cavity

EREBROSP|NALfluid (CSF) leakage into the paranasal sinuses or mastoid cells, and rhinorrhea or otorrhea have been well documented; however, CSF leakage into the orbital cavity accompanied by clinical symptoms has rarely been described. The orbit is practically a closed cavity and therefore pressure flow of CSF cannot exist between the subarachnoid space and the orbital cavity. This fact may constitute a major reason for reported cases of a nearly asymptomatic course and spontaneous resolution of CSF leakage into the orbital cavity. We are presenting an unusual case of a fistula between the orbit and lateral ventricle of traumatic origin. To our knowledge, such a case has not previously been reported in the medical literature.

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C a s e Report

A 10-month-old boy was admitted to the hospital 10 hours after sustaining a head in-

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jury. He fell down a stairway in his baby stroller and hit his forehead on a concrete floor. He did not lose consciousness, and left supraorbital ecchymosis and swelling of the left lids were the only symptoms seen. There was no bleeding from the nose or ear. Ten hours later, however, he vomited several times and the swelling with ecchymosis of the left lids had progressed. He was referred to us for examination by his family physician. Examination. On admission, the patient was fussy and uncooperative but alert. The left eye was almost closed because of marked periorbital swelling with ecchymosis. The left eye was displaced downward, with slight lateral deviation of the globe; the pupil was dilated unilaterally. There was no anesthesia of the forehead. A skull film showed a linear fracture in the left frontal area extending into the roof of the orbit. These projection films for optic canals revealed no abnormality. There was no pneumocephalus. Left carotid angiography was carried out because of

J. Neurosurg. / Volume 43 / December, 1975

Ventriculo-orbital fistula in closed head injury anisocoria, and revealed a slight shift of the anterior cerebral artery, but no extracerebral hematoma. The patient was treated conservatively for 7 days with hemostatic and prophylactic antibiotics. The left periorbital edema and ecchymosis gradually subsided, but downward displacement and lateral deviation of the globe persisted. Upward gaze was impossible, probably because of malfunction of the superior rectal muscle. Proptosis and pulsation of the globe was not evident; the anisocoria disappeared and the ophthalmoscopic examination disclosed no abnormality. On palpation, a fracture cleft and a small area of fluctuation around it was felt at the left superior orbital rim. By percutaneous needle aspiration through this cleft we obtained 20 ml of blood-tinged CSF. This aspiration resuited in prompt but temporary restoration of the left eye to its normal position. The recurrence of the eye displacement soon after removal of the needle suggested free communication between the orbital cavity and the subarachnoid space. For the purpose of visualization of this connecting pathway, a 22-gauge needle was inserted through the fracture cleft into the orbital cavity. Immediately after aspiration of 10 ml of CSF, 5 ml of 60% meglumine iothalamate (Conray) was injected slowly under x-ray television image control. A bizarre fistulous connection between the left orbital cavity and the left lateral ventricle was demonstrated. The whole ventricular system including the aqueduct and fourth ventricle was visualized but the Conray did not spread into the subarachnoid space (Fig. 1). After the study, the Conray was aspirated out and washed away with saline; no untoward reaction occurred. Operation. Left frontal craniotomy confirmed a linear fracture from the frontal to orbital roof and disclosed a dural laceration about 2 cm in length along the orbital roof fracture. A lacerated dural edge was held fast in the fracture cleft. An irregular fistulous pathway ran from the base of the frontal tip just above the dural laceration to the anterior horn of the left lateral ventricle through the frontal lobe; clear CSF flowed copiously from the fistula. Devitalized brain tissue around the fistula was removed by suction and torn dura was tightly closed by interrupted sutures. A small round part of the orbital roof, measuring 6 X 6 ram, was cut away with a rongeur,

J. Neurosurg. / Volume 43 / December, 1975

FI~ 1. Percutaneous injection of 5 ml of undiluted Conray into the fistula with satisfactory visualization of the fistula and the whole ventricular system.

and the orbital cavity was explored, but no abnormality was disclosed. Postoperative Course. The left eye returned to its normal position, and the patient recovered uneventfully. He was discharged 2 weeks after operation with prophylactic anticonvulsant medication. He is currently very well, 7 months postoperatively. Discussion An orbital roof fracture with dural and paranasal sinus involvement is not uncommon and rhinorrhea usually results. In a case of orbital roof and superior orbital rim fracture without involvement of a paranasal sinus, it is reasonable to expect some CSF to leak into the orbital cavity; if it leaks in sufficient volume, it may produce ocular symptoms. Indeed, temporary displacement of the globe, diplopia, exophthalmos, and disturbance of upward gaze are commonly seen in these cases. These symptoms are usually attributed to an intraorbital hematoma or edema, probably by association of marked periorbital ecchymosis and edema, but in some cases, compression ofintraorbital structures by leaking CSF may be a causative factor. A few cases of traumatic pseudomeningocele or encephalomeningocele in the orbit have been reported, a'~'4 but CSF leakage 755

H. Terao and S. Sato into the orbital cavity usually resolves spontaneously without any residual symptoms. In our case, a broad fistulous connection developed between the anterior horn of the lateral ventricle and the orbit through the cerebral parenchyma, and a fairly large volume of CSF, probably under some pressure, invaded the upper part of the orbital cavity. Spontaneous closure could not be expected. This kind of ventricular fistula is uncommon in a closed head injury; however, in some cases of traumatic pneumocephalus, a certain amount of air was apparent in the lateral ventricle on x-ray film, which is indirect evidence of the presence of a traumatic ventricular fistula. To determine the location of the dural or ventricular fistula, retrograde injection or instillation of contrast medium, usually Pantopaque, has been attempted, with or without success? ,5 In our case, Conray was used with satisfactory results for radiological visualization of a ventriculo-orbital fistula. Conray has an advantage because of its low viscosity, but it should not be used without fluoroscopic or x-ray television control, because dangerous reactions may result from the Conray spilling into the subarachnoid space.

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References Bhandari YS: Traumatic orbital pseudomeningocele. Case report. J Neurosurg 30:612-614, 1969 Jungmann A, Peyser E: Roentgen visualization of cerebrospinal fluid fistula with contrast medium. Radiology 80:92-95, 1963 King AB: Traumatic encephaloceles of the orbit. Arch Ophthalmol 46:49-56, 1951 Taptas JN: L6sions traumatiques des parois orbitaires. R6percussion sur le globe oculaire: pulsabilit6 du globe par lacune osseuse au plafond de l'orbite et exorbitisme par pseudom6ningoc~le. A p r o p o s de deux observations. Presse Med 72:3383-3384, 1964 Teng P, Edalatpour N: Cerebrospinal fluid rhinorrhea with demonstration of cranionasal fistula with Pantopaque. Radiology 81: 802-806, 1963

Address reprint requests to: Hideo Terao, M.D., Neurosurgical Service, Tokyo Komagome Municipal Hospital, Honkomagome 3-chome 1822, Bunkyo-ku, Tokyo, Japan.

J. Neurosurg. / Volume 43 / December, 1975

Ventriculo-orbital fistula in closed head injury. Case report.

A ventriculo-orbital fistula developing as a result of closed head injury produced intraorbital compression symptoms including downward deviation of t...
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