Raccoon Sign


Article Author:
Joe M Das


Article Editor:
Sunil Munakomi


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
11/10/2019 1:39:36 PM

Definition/Introduction

Synonyms: raccoon eyes, raccoon sign, panda sign, periorbital ecchymosis or periorbital hematoma

The clinical triad comprising of unilateral or bilateral progressive proptosis, periorbital ecchymosis, and edema is called raccoon sign.[1]

The pooling of blood around the eyes is most commonly associated with fractures of the anterior cranial fossa. This finding is typically not present during the initial evaluation and delays by 1 to 3 days.[2] If bilateral, this finding is highly predictive of a basilar skull fracture. Classically, the tarsal plate will be spared. Further extravasation of the blood beyond the periorbital region is limited owing to the orbital septum inserting into the tarsal plate.[3]

When a skull base fracture is present, the raccoon sign is present in 50 to 60% of cases.[4] This sign can be easily identified and is usually associated with anterior skull base fractures, especially of the frontal bone with an associated epidural hematoma. Thin-cuts computed tomogram of the skull (less than 5 mm) is needed to identify the fracture in some cases.

Issues of Concern

If the raccoon sign is present in a trauma victim, one should be aware of the following associated injuries or complications:

  1. Cerebrospinal fluid (CSF) rhinorrhea
  2. Injury to eyeballs
  3. Injury to cranial nerves I, II, III, IV, VI
  4. Intracranial misplacement of the nasogastric or nasotracheal tube
  5. Diffuse axonal injury
  6. Insult to the hypothalamic-pituitary axis (HPA) leading to endocrinopathies
  7. Maxillofacial injuries
  8. Cervical spine injury
  9. Meningitis, at a later stage

Clinical Significance

Although commonly associated with skull base fracture, raccoon sign may also present in a variety of other conditions (limited to case reports), which include:

  1. Traumatic: unilateral and bilateral orbital fractures[4][5][6][7][8][9][10]:
    1. Minor periorbital trauma, like the plucking of eyebrows
    2. Non-accidental injuries
    3. Thoracic trauma and crush injuries
    4. Following vigorous sneezing, coughing or vomiting - probably due to periorbital venous hemorrhage
    5. Posttraumatic orbital emphysema (due to fracture of orbital wall and entrapment of air from paranasal sinuses)
  2. Vascular[11][12][13][14][15][16][17][18]:
    1. Subarachnoid hemorrhage (SAH) from ophthalmic artery aneurysm
    2. Sinus thrombosis - dural, superior sagittal sinus, and cavernous sinus thrombosis
    3. Giant cell arteritis
    4. Trigeminal autonomic cephalalgia
    5. Benign intracranial hypertension
    6. Acute migraine (due to vasodilation and release of vasoactive substances including heparin)
  3. Infectious[19][20][21][20][19]:
    1. Severe pediatric adenovirus infection
    2. Periorbital leukoderma
    3. Frontal sinus mucocele
  4. Immune-mediated[22][23][24][25]:
    1. The neonatal lupus erythematosus (vasculitis may lead to facial and periorbital purplish-red plaques)
    2. Chronic atypical neutrophilic dermatosis with lipodystrophy and elevated temperature (CANDLE) syndrome (neutrophilia and skin lesions containing mature neutrophils may also cause raccoon eyes appearance due to periorbital erythematous edema; due to a predilection to involve periorbital skin)
    3. Lichen planus pigmentosus (hyperpigmentation due to pigment incontinence)
    4. Sweet syndrome or acute febrile neutrophilic dermatosis is a skin disease characterized by the sudden onset of fever, an elevated white blood cell count, and tender, red, well-demarcated papules, and plaques that show dense infiltrates by neutrophil granulocytes on histologic examination
      • Raccoon sign in this condition is due to secondary vascular damage caused by prolonged exposure to matrix metalloproteinases
      • Toxic products of neutrophils in the infiltrate may be responsible for vascular damage leading to erythrocyte extravasation
  5. Metabolic[26][27]:
    1. Amyloidosis (most commonly, light chain (AL) type) – due to increased vascular fragility as a result of amyloid deposition - this is one of the most common causes of raccoon eyes other than trauma; the finding presents in about one-fifth of patients with AL amyloidosis
    2. Myxedema
  6. Malignancies[28][29][30][1][31][32][33][34]:
    1. Hematological malignancies: blastic plasmacytoid dendritic cell neoplasm, lymphoblastic lymphoma, acute myeloid leukemia
    2. Metastatic neuroblastoma (secondary to tumoral obstruction of the palpebral vessels): neuroblastoma can present as periorbital ecchymosis in 5.4% of cases
    3. Orbital metastasis of solid malignancies
    4. Kaposi sarcoma
    5. Multiple myelomas: Infiltration of amyloid proteins in the capillaries lead to increased fragility, which can burst under minor stress, resulting in raccoon sign - usually, such an ecchymosis is painful in multiple myeloma
  7. Genetic:
    1. Hemophilia
  8. Iatrogenic (perioperative raccoon eyes)[35][36][37][38]:
    1. Usually associated with systemic amyloidosis of AL type .
    2. Post-rhinoplasty (due to a bleeding disorder)
    3. Post-endoscopic retrograde cholangiopancreatography (ERCP) (prone positioning, consumption of steroid and Valsalva maneuver might cause increased venous pressure which in turn lead to the rupture of fragile vessels in the orbit of an elderly patient)

Nursing Actions and Interventions

If a nurse encounters a patient with a raccoon sign, he or she should immediately ask about a history of trauma, CSF rhinorrhea, and difficulty in vision. One should avoid inserting a nasogastric tube in such patients as intracranial placement of the tube may occur accidentally. It is better to place the orogastric tube instead, if necessary.

The periorbital ecchymosis perse resolves within 2 to 3 weeks.


  • Image 5070 Not availableImage 5070 Not available
    Contributed by Tammy J. Toney-Butler, AS, RN, CEN, TCRN, CPEN, Images Courtesy of S Bhimji, Ph.D., MD, MSc
Attributed To: Contributed by Tammy J. Toney-Butler, AS, RN, CEN, TCRN, CPEN, Images Courtesy of S Bhimji, Ph.D., MD, MSc

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Raccoon Sign - Questions

Take a quiz of the questions on this article.

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A 20-year-old male patient was brought to the emergency department following a physical assault with a metal rod on the head. On examination, the physician noted that his Glasgow Coma Scale score was 15 and there was a bluish discoloration behind his right ear. Fracture of which bone is consistently associated with the injury shown in the image?

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    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD



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An 18-year-old male was brought to the emergency room following a motor vehicle collision. On secondary survey, he was found to have the findings as seen in the picture. What are the bones likely to be fractured?

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    Contributed by Tammy J. Toney-Butler, AS, RN, CEN, TCRN, CPEN. Images Courtesy of S Bhimji, Ph.D., MD, MSc
Attributed To: Contributed by Tammy J. Toney-Butler, AS, RN, CEN, TCRN, CPEN. Images Courtesy of S Bhimji, Ph.D., MD, MSc



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A 70-year-old lady presents to the hospital with what appears to be "raccoon eyes". There is no history of trauma. What is the most likely etiology?



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A 4-year-old boy presented with spontaneous Raccoon eyes. There was no history of trauma or coagulopathy. On examination, he had a non-tender abdominal lump. Which of the following is the strongest predictor of poor prognosis in this child?



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A patient was found to have bilateral periorbital swelling and ecchymosis following a physical assault. What anatomical structure accounts for limiting further extravasation of blood beyond the periorbita resulting in the characteristics eye sign?



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Raccoon Sign - References

References

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Herbella FA,Mudo M,Delmonti C,Braga FM,Del Grande JC, 'Raccoon eyes' (periorbital haematoma) as a sign of skull base fracture. Injury. 2001 Dec;     [PubMed]
Aalbers M,van Dijk JMC, Teaching NeuroImages: Raccoon eye in subarachnoid hemorrhage. Neurology. 2019 Mar 26;     [PubMed]
Matsuura H,Anzai Y,Kuninaga N,Maeda T, Raccoon Eye Appearance: Amyloidosis. The American journal of medicine. 2018 Jul;     [PubMed]
Musarella MA,Chan HS,DeBoer G,Gallie BL, Ocular involvement in neuroblastoma: prognostic implications. Ophthalmology. 1984 Aug;     [PubMed]
Wisuthsarewong W,Soongswang J,Chantorn R, Neonatal lupus erythematosus: clinical character, investigation, and outcome. Pediatric dermatology. 2011 Mar-Apr;     [PubMed]
Law DZ,Vahdani K,Ashdown M,Garrott H,Ford RL, Periorbital linear lichen planus pigmentosus-report of 2 cases and literature review. Canadian journal of ophthalmology. Journal canadien d'ophtalmologie. 2019 Feb;     [PubMed]
Torrelo A, CANDLE Syndrome As a Paradigm of Proteasome-Related Autoinflammation. Frontiers in immunology. 2017;     [PubMed]
Salman A,Demir G,Cinel L,Oguzsoy T,Yıldızhan G,Ergun T, Expanding the differential diagnosis of raccoon eyes: sweet syndrome. Journal of the European Academy of Dermatology and Venereology : JEADV. 2019 Jan;     [PubMed]
Satyarthee GD,Sharma BS, Posttraumatic orbital emphysema in a 7-year-old girl associated with bilateral raccoon eyes: Revisit of rare clinical emergency, with potential for rapid visual deterioration. Journal of pediatric neurosciences. 2015 Apr-Jun;     [PubMed]
Liu YT,Yang MH,Cao LZ,Huang YH,Xie M,Yang LC,Yang H,Tang X, [Painless skin nodules and ecchymosis in a school-aged girl]. Zhongguo dang dai er ke za zhi = Chinese journal of contemporary pediatrics. 2015 Oct;     [PubMed]
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Deakin CD, Bilateral periorbital hematoma (raccoon eyes) following thoracic crush injuries: case reports. The Journal of trauma. 1995 May;     [PubMed]
Maramattom BV, Raccoon eyes following vigorous sneezing. Neurocritical care. 2006;     [PubMed]
Reid JM,Williams D, Panda sign due to severe coughing. The journal of the Royal College of Physicians of Edinburgh. 2013;     [PubMed]
Al-Sardar H, Recurrent bilateral periorbital and circumoral bruising due to vomiting. BMJ case reports. 2014 Apr 2;     [PubMed]
Cheng FW,Ho AC,Li CK, Raccoon eyes as presentation of lymphoblastic lymphoma in a child. British journal of haematology. 2013 Jul;     [PubMed]
Fernandez S,Adhiyaman V, Giant cell arteritis presenting as peri-orbital ecchymosis. Age and ageing. 2005 Jan;     [PubMed]
Attanasio A,D'Amico D,Frediani F,Leone M,Grazzi L,Bianchi-Marzoli S,Usai S,Bussone G, Trigeminal autonomic cephalgia with periorbital ecchymosis, ocular hemorrhage, hypertension and behavioral alterations. Pain. 2000 Oct;     [PubMed]
Chuang Yu,Chiu CH,Wong KS,Huang JG,Huang YC,Chang LY,Lin TY, Severe adenovirus infection in children. Journal of microbiology, immunology, and infection = Wei mian yu gan ran za zhi. 2003 Mar;     [PubMed]
Goette DK, Raccoon-like periorbital leukoderma from contact with swim goggles. Contact dermatitis. 1984 Mar;     [PubMed]
Weingarten TN,Hall BA,Richardson BF,Hofer RE,Sprung J, Periorbital ecchymoses during general anesthesia in a patient with primary amyloidosis: a harbinger for bleeding? Anesthesia and analgesia. 2007 Dec;     [PubMed]
Kim GH,Lee WK,Na SH,Lee JS, Undiagnosed light chain systemic amyloidosis: does it matter to anesthesiologists? -a case report-. Korean journal of anesthesiology. 2013 Nov;     [PubMed]
Kumar V,Ghosh B,Raina UK,Goel N, Bilateral periorbital ecchymosis in a case with dengue fever. Indian journal of ophthalmology. 2009 May-Jun;     [PubMed]
Nasiri J,Zamani F, Periorbital Ecchymosis (Raccoon Eye) and Orbital Hematoma following Endoscopic Retrograde Cholangiopancreatography. Case reports in gastroenterology. 2017 Jan-Apr;     [PubMed]
Kandogan T,Aydar L,Yalciner B, Bilateral black eyes,     [PubMed]
Loo H,Forman WB,Levine MR,Crum ED,Rassiga AL, Periorbital ecchymoses as the initial sign in multiple myeloma. Annals of ophthalmology. 1982 Nov;     [PubMed]
Inokuchi R,Tagami S,Maehara H, An elderly woman with bilateral raccoon eyes. Emergency medicine journal : EMJ. 2016 Nov;     [PubMed]
de Moura CG,Cruz CM,de Souza SP, Raccoon sign. Arthritis and rheumatism. 2013 Mar;     [PubMed]
Solai CA,Domingues CA,Nogueira LS,de Sousa RMC, Clinical Signs of Basilar Skull Fracture and Their Predictive Value in Diagnosis of This Injury. Journal of trauma nursing : the official journal of the Society of Trauma Nurses. 2018 Sep/Oct;     [PubMed]
Hadjikoutis S,Carroll C,Plant GT, Raised intracranial pressure presenting with spontaneous periorbital bruising: two case reports. Journal of neurology, neurosurgery, and psychiatry. 2004 Aug;     [PubMed]
Roy PM,Gras E, Images in clinical medicine. Cerebral venous thrombosis. The New England journal of medicine. 2003 Oct 30;     [PubMed]
Clifford-Jones RE,Ellis CJ,Stevens JM,Turner A, Cavernous sinus thrombosis. Journal of neurology, neurosurgery, and psychiatry. 1982 Dec;     [PubMed]
McCasland BJ,Mendicino ME,Newman NJ, Subretinal haemorrhage in idiopathic intracranial hypertension. The British journal of ophthalmology. 1999 Jul;     [PubMed]
DeBroff BM,Spierings EL, Migraine associated with periorbital ecchymosis. Headache. 1990 Apr;     [PubMed]
Karmegaraj B,Latha M S,Manipriya R,Vijayakumar S,Rajendran A,Maljetty V,Samikannu R,Scott JX, Periorbital chloroma mimicking raccoon eyes in a child with acute myeloid leukaemia. Archives of disease in childhood. 2014 Nov;     [PubMed]
Mehta AA,Wagner LH,Blace N, Spontaneous upper eyelid ecchymosis: A rare presenting sign for frontal sinus mucocele. Orbit (Amsterdam, Netherlands). 2017 Jun;     [PubMed]
McPheeters RA,White S,Winter A, Raccoon eyes. The western journal of emergency medicine. 2010 Feb     [PubMed]

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