The significance of periorbital ecchymosis (‘racoon eyes’) appearing shortly after a neurointerventional procedure may be overlooked, particularly in the setting of intervention distant from the ocular venous drainage system in an otherwise neurologically stable patient. This seemingly innocuous sign may be indicative of subarachnoid hemorrhage from procedure related arterial dissection.

An 82-year-old man on aspirin and clopidogrel underwent elective right middle cerebral artery (distant M1 segment) angioplasty and stent placement for recurrent orthostatic transient ischemic attack. Vessels were noted to be tortuous but otherwise the procedure was completed without obvious complication. While recovering from the general anesthesia, bilateral periorbital ecchymosis was noted (figure 1A). A routine 24 h postprocedure hospital stay was unremarkable aside from a complaint of a mild headache but without any new neurological deficit. He was readmitted 2 days later due to persistent headache and mild confusion. Brain CT now disclosed subarachnoid hemorrhage (figure 1B). Periorbital ecchymosis, confusion and headache all resolved over several days.

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Figure 1

(A) Bilateral periorbital ecchymosis. (B) Non-contrast head CT demonstrating right cerebral subarachonid hemorrhage.

Venous drainage of the orbit and eyelid is mainly from the superior/inferior orbital and angular veins, which are all valveless, draining into the cavernous sinus. In contrast with other major intracranial veins where the thick dura completely surrounds the veins, cavernous sinus is only partially covered. Compression of the cavernous sinus during a transient intracranial pressure (ICP) elevation may lead to orbital and periorbital tissue venous hypertension with subsequent rupture. Retinal hemorrhage, frequently observed even in alert neurologically normal patients, has been well established as a classic clinical sign of subarachnoid hemorrhage,1 and engorged and dilated superior orbital vein has been emphasized as a radiologic sign of elevated ICP.2 Hadjikoutis et al3 have already documented eyelid ecchymosis in their two cases of sagittal sinus thrombosis and postulated the same physical sign may be seen in subarachnoid hemorrhage patients from a transient ICP elevation.

The presence of ‘racoon eyes’, although better known as a physical sign of a frontal skull fracture following head trauma, if present following a neurointerventional procedure, suggests procedure related arterial dissection resulting in subarachnoid hemorrhage.