Orbit, 2014; 33(3): 226–228 ! Informa Healthcare USA, Inc. ISSN: 0167-6830 print / 1744-5108 online DOI: 10.3109/01676830.2014.894539


Emesis-induced Sub-periosteal Haematoma: A Case Report Jennifer R. Reid1, Saul N. Rajak1,2, C. D. Good1, and G. Paul Brittain1 1

Sussex Eye Hospital, Brighton and Sussex University Hospital, Brighton BN2 5BE, United Kingdom and 2 The London School of Hygiene and Tropical Medicine, London BN2 5BF, United Kingdom

ABSTRACT Background: Orbital sub-periosteal haematoma (OSH) is usually caused by orbital trauma. We present a case of spontaneous OSH and review the literature on this condition. Methods: We present a case of sub-periosteal haematoma secondary to migraine and vigorous emesis. Discussion: OSH is very rare; this case highlights the clinical features of the condition and that rapid spontaneous resolution can occur. We review the literature on emesis- or valsava-induced OSH and discuss possible mechanisms for its formation in conjunction with migraine. Keywords: Emesis, haematoma, migraine, sub-periosteal


proptosis, (3 mm greater than left eye). There was a marked restriction of right upgaze and moderate restriction of right abduction and adduction. She had a left superior homonymous quadrantinopia. The visual acuity was 6/6 unaided bilaterally. Pupillary responses and optic nerve function in both eyes was normal. Blood tests including a coagulation screen were normal. An orbital MRI scan showed a right sub-periosteal mass with intermediate T1, moderately bright T2, low T2*signal consistent with hyperacute haemorrhage (Figure 2a). There was no compression at the orbital apex and no intracranial extension of the haemorrhage. MRI and MRA of the brain were unremarkable. The patient received conservative management with bed-rest, intravenous anti-emetics and analgesia for 24 hours. A repeat visual fields assessment on the following day found the quadrantinopia had resolved and the patient was discharged. She was next reviewed 3 weeks later and the diplopia and lid ecchymosis had resolved. The MRI scan was repeated 9 weeks after the initial presentation and showed

Orbital sub-periosteal haematoma (OSH) derives from a ruptured subperiosteal blood vessel. This usually results from orbital trauma, but occasionally occurs spontaneously. We present a case of OSH, which occurred after a migraine associated with vigorous vomiting. We discuss the possible pathophysiology of the condition and review the literature on the subject.

Case Report A 22-year-old Caucasian woman presented with vertical diplopia and retrobulbar eye pain, which had developed immediately after a migraine with vigorous emesis. She was known to have frequent, severe migraines for which she took propanolol. She had no other comorbidities and no history of trauma. On examination she was found to have right upper and lower lid ecchymosis (Figure 1) and right eye

Received 11 September 2013; Revised 18 January 2014; Accepted 11 February 2014; Published online 20 March 2014 Correspondence: Saul N. Rajak, Sussex Eye Hospital, Eastern Road, Brighton BN2 5BF. Tel: 00 44 (0)1273 696955. Fax: 01273 693 674. E-mail: [email protected]


Emesis-induced Sub-periosteal Haematoma 227 complete resolution of the haemorrhage (Figure 2b). The patient has since had subsequent migraines with similar vigorous vomiting, without recurrence of the OSH.

DISCUSSION OSH usually results from direct facial or orbital trauma, although has been reported after surgery and in patients with vascular abnormalities and blood dyscrasias.1 Emesis- or valsava-induced OSH is extremely rare with very few cases having been reported in the literature (Table 1). The present case highlights the dramatic presentation of this condition and is particularly interesting for the concurrent visual field defect and the rapid spontaneous resolution with conservative management.

Seven cases of emesis- or valsava-induced OSH have been reported (Table 1). Three of these appear to have been precipitated by vomiting with one of them occurring after migrainous episode. All the cases have features of a pressure gradient: either ‘‘internally’’ between thoracic/abdominal cavities and orbit, or ‘‘externally’’ between a scuba mask and the orbit, which may precipitate the rupture of a predisposed vessel. Emesis-induced OSH is probably caused by increased intra-abdominal and intra-thoracic pressures, causing increased jugular venous pressure, which is transmitted to the orbit causing rupture of a bridging sub-periorbital vessel.4,5 The precise pathophysiology of migraine remains elusive, with both vascular and neuronal theories being proposed, although the neuronal theory has gained more support in recent years. However, migraine is known to be associated with a higher risk of cerebrovascular accidents. This is thought to be due to vasoconstriction, oilgaemia and focal ischaemia, followed by a rapid increase in cerebral blood flow in the later phase of a migrainous episode. It is plausible that these vascular changes, and in particular the reactive increase in blood-flow in association with raised pressure caused by vomiting precipitated the haematoma. The homonymous quadrantinopia at presentation was initially strongly suggestive of a cerebrovascular accident. However, the normal brain MRI scan and rapid resolution of the visual field indicated it to have been caused by the migraine, resolving the diagnostic conundrum at presentation. Most of the previously reported cases of spontaneous OSH were managed by surgical evacuation of the haemorrhage. However, the present case highlighted that OSH can in fact resorb rapidly, obviating the need for surgical intervention, unless there is significant risk to the optic nerve or other vital orbital structures.

FIGURE 1. Right eye at presentation.

FIGURE 2. MRI orbit. (a) Intermediate signal T1 acute sub-periosteal haematoma on the roof of the right orbit. (b) 9 weeks post-presentation, showing complete resolution of the haematoma with no mass effect in the orbit. !

2014 Informa Healthcare USA, Inc.

228 J. R. Reid et al. TABLE 1. Review of reported cases of valsalva-induced sub-periosteal orbital haematoma. Author






Anterior orbitotomy, after 10 days

Crawford and Mazzoli2


Rosenberry et al.3


Boyer and Lucarelli4


Jacobson et al.5


Katz and Carmody6


Katz and Abrams7


22-year-old female Emesis after heavy drinking 44-year-old male Valsalva manoeuvre to relieve ‘‘mask squeeze’’ while scuba diving 45-year-old male Unequilibrated pressure in his scuba diving mask 37-year-old male Emesis after a typical migraine episode 20-year-old female During labour 23-year-old male Lifting weights 9-year-old male After an episode of vomiting due to influenza

Crawford and Mazzoli

Anterior orbitotomy, after 5 days

Anterior orbitotomy, after 2 days

Observation, resolution in 3 weeks Observation, resolution during the following 2 weeks Observation, resolution without intervention Observation, resolution without intervention



Emesis or valsava induced sub-periosteal haematoma is an extremely rare event with just 7 previously reported cases. The possible cause and pathophysiology have been discussed and in the absence of significant risk to any vital orbital structures, conservative management was shown to be effective.

1. Guirgis MF, Segal WA, Lueder GT. Subperiosteal orbital hemorrhage as initial manifestation of Christmas disease (factor IX deficiency). Am J Ophthalmol 2002; 133(4):584–585. 2. Crawford C, Mazzoli R. Subperiosteal hematoma in multiple settings. Digit J Ophthalmol 2013;19(1):6–8. 3. Rosenberry C, Angelidis M, Devita D. Orbital subperiosteal hematoma from scuba diving. Wilderness Environ Med 2010;21(3):250–252. 4. Boyer MM, Lucarelli MJ. Valsalva-induced subperiorbital hemorrhage during migraine. Arch Ophthalmol 1998; 116(1):106–107. 5. Jacobson DM, Itani K, Digre KB, et al. Maternal orbital hematoma associated with labor. Am J Ophthalmol 1988; 105(5):547–553. 6. Katz B, Carmody R. Subperiosteal orbital hematoma induced by the valsalva maneuver. Am J Ophthalmol 1985; 100(4):617–618. 7. Katz RS, Abrams G. Orbital subperiosteal hematoma (epidural hematoma of the orbit). J Clin Neuroophthalmol 1981;1(1):45–52.

ACKNOWLEDGMENTS Consent to publication was obtained from the patient.

DECLARATION OF INTEREST The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.


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Emesis-induced sub-periosteal haematoma: a case report.

Orbital sub-periosteal haematoma (OSH) is usually caused by orbital trauma. We present a case of spontaneous OSH and review the literature on this con...
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