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