What are Raccoon Eyes?

Raccoon eyes (periorbital ecchymosis) refer to bilateral or unilateral dark bruising around the eyes following head trauma. The characteristic appearance results from blood tracking along fascial planes into the periorbital region, confined by the orbital septum. This clinical sign is most commonly associated with fractures of the anterior cranial fossa.

Importantly, raccoon eyes may not appear immediately — they typically develop 1–3 days after initial injury as blood continues to track along tissue planes. The presence of raccoon eyes, when bilateral and not caused by direct periorbital trauma, has strong predictive value for an underlying basilar skull fracture.

PRIMARY: Herbella FA, et al. 'Raccoon eyes' (periorbital haematoma) as a sign of skull base fracture. Injury. 2001;32(10):745–747. [PMID: 11754879]

SUPPORTING: Simon LV, Newton EJ. Basilar Skull Fractures. StatPearls [Updated Aug 2023]. PMID: 29489178

SUPPORTING: McPheeters RA, White S, Winter A. Raccoon eyes. West J Emerg Med. 2010;11(1):97. [PMC2850869]

SUPPORTING: Solai CA, et al. Clinical Signs of Basilar Skull Fracture and Their Predictive Value. J Trauma Nurs. 2018;25(5):301–306. [PMID: 30216260]

Common Causes

• Basilar skull fracture (anterior cranial fossa)
• Facial fractures with periorbital involvement
• Severe blunt head trauma
• Road traffic accidents
• Falls from height
• Sports injuries

Investigations

• CT Head (investigation of choice in acute settings)
• CT Facial Bones (if facial fracture suspected)
• MRI Brain (selected cases for soft-tissue detail)
• Neurological examination
• Skull base assessment

Plain skull X-rays are not sensitive for detecting basilar skull fractures. Multi-detector CT (MDCT) with thin-slice scanning is recommended when basilar fracture is clinically suspected.

Simon LV, Newton EJ. Basilar Skull Fractures. StatPearls [Updated Aug 2023]. PMID: 29489178

Clinical Significance

Clear fluid draining from the nose (CSF rhinorrhea) or ear canal (CSF otorrhea) following head trauma represents a neurological emergency. This fluid is cerebrospinal fluid (CSF) — the protective fluid circulating in the subarachnoid space around the brain and spinal cord — and its leakage almost always indicates a defect in the dura mater overlying a skull base fracture.

CSF leaks carry a significant risk of ascending bacterial meningitis (predominantly Streptococcus pneumoniae), with estimated meningitis rates of approximately 10–25% in untreated post-traumatic CSF leaks. The risk increases with duration of the leak.

Ziu M, Savage JG, Jimenez DF. Diagnosis and treatment of cerebrospinal fluid rhinorrhea following accidental traumatic anterior skull base fractures. Neurosurg Focus. 2012;32(6):E3. doi:10.3171/2012.4.FOCUS1264 — Key reference for post-traumatic CSF leak management.

Common Causes

• Basilar skull fracture (anterior or middle cranial fossa)
• Severe blunt head trauma
• Penetrating skull injuries
• Surgical complications (post-neurosurgical)
• Spontaneous CSF leak (idiopathic intracranial hypertension — non-traumatic)

Investigations

• CT Head (initial imaging)
• High-resolution CT Skull Base (thin cuts, 1mm)
• MRI Brain with cisternography (to localise leak site)
• Beta-2 transferrin assay (gold standard biochemical test for CSF identification)
• Fluorescein nasal endoscopy (specialist setting)

Beta-2 transferrin is a protein almost exclusively found in CSF, vitreous humor, and perilymph. Its identification in nasal or aural discharge is the most reliable biochemical confirmation of CSF leakage.

Management

• Conservative: bed rest, head elevation, avoid nose blowing, stool softeners, avoid straining
• Lumbar drain (selected cases to reduce CSF pressure)
• Neurosurgical repair: endoscopic or open surgical repair when conservative management fails (typically after 7–14 days)
• Antibiotics: prophylactic antibiotic use remains controversial; most guidelines advise against routine prophylaxis