Contre-coup extradural haematoma : a short report.

A Mishra, S Mohanty 
 Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221005, India., India

Correspondence Address:
A Mishra
Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221005, India.
India

Full Text

::   Introduction

Extradural haematoma (EDH) usually occurs as a

result of direct impact injuries of the head, ipsilateral

to impact side.[1],[3] These are frequently associated with

local scalp bruise or linear fracture, although

occasional extradural haematoma without skull

fractures have been reported, mostly in patients under

30 years of age.[3] Contact related skull deformation,

causes inbending or fracturing of cranium or both,

leading to separation of dura from inner table. This

injures the dural arteries, veins, venous sinus or

diploid channels, producing EDH.[3] Review of

literature reveals no report of contre-coup extradural

haematoma, although bilateral EDH have been

reported.

::   Case report

A 50 year old male presented with complaint of

alleged assault over left frontoparietal region with axe.

He was unconscious since the injury with no history

of vomiting, seizures, bleeding from ear, nose or

throat. On examination a lacerated scalp wound was

present over left fronto-parietal region. He was in E1,

V1, M1 of glasgow coma scale (GCS). Pupils were

bilaterally dilated and non reacting, with pulse of

52/min. CT scan revealed large extradural haematoma

in right fronto-parietal lesion, left fronto-parietal

intracerebral contusional haematoma [Figure 1] with

fracture left fronto-parietal bone [Figure 2]. Mannitol

(20%) 150 ml IV was started and patient shifted to

emergency operation theatre. GCS improved to

E1,V2,M3 after anti-oedema measures. Right pupil

remained dilated and fixed and the left semi-dilated

and sluggishly reacting. Left hemiplegia was deteted.

Right fronto-parietal trephine cranitomy with

evacuation of extradural haematoma was done under

general anaesthesia. Post-operatively patient's

recovery was very slow but in next 2 weeks he

improved to GCS-E4,V5,M6. Pupil returned to

normal size and hemiparesis also improved.

::   Discussion

Incidence of extradural haematoma is 1-3% of all

head injuries.[3] Although contre-coup contusions and

acute subdural haematoma, resulting from head

acceleration have been reported, no case of pure

contre-coup extradural haematoma has been

reported.[3] In the present case, it was very surprising

that contact injury was on the left fronto-parietal

region leading to fracture of only left parietal bone

and underlying intracerebral haematoma, but a large

extradural haematoma was present on the opposite

side in the right fronto-parietal region. One may raise

the question that patient may get injuty to right side

while falling to the ground or mulitple blows to head,

but there was no evidence of external injury i.e. bruise

over scalp on the right side and no fracture was

present on the right fronto-parietal region. Rebound

effect after impact on skull was demonstrated by

Hooper.[3] There is a constant relationship that the

haematoma bears to scalp bruising than to fracture.

In 230 consecutive cases of extradural haematoma,

there were 7 cases of bilateral extradural haematoma,

of which 4 cases were bifrontal, one bitemporal, one

bilateral occipital. The bitemporal EDH was in the

base of middle cranial fossa associated with basal

fracture and optic injury.[1] According to Jamiesson4

extradural haematoma is never contre-coup but may

be bilateal when midline vessel (the sagittal sinus) is

invloved or multiple blows have been experienced.

Balasubraminium and Ramesh[2] reported an unusual

type of bilateral extradural haematoma, one due to

direct injuty and another due to the contre-coup effect.

The second evolved after the first haematoma and was

evacuated. They observed that local deformation at the

site of impact produces a simultaneous lucking effect

of calvarium exactly opposite the impact site, giving

rise to a small pocket brought on by stripping of dura.

This deformation and 'reliance effect' produced by

evacuation of first haematoma was responsible for

contre-coup haematoma. Miyazaki et al[5] also reported

a case of bilateral extradural haematoma . One due to

coup injuty and other due to contre-coup injury.

According to them appearance of haematoma resulted

from the dural separation due to distortion of the

cranium brought on by the force of impact. In our

patient contre-coup skull deformation following the

impact was responsible for the formation of contrecoup

extradural haematoma.

References