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Acute epidural haematoma due to contrecoup head injury: a case report ARTICLE
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Available from: Mucahit Emet Retrieved on: 16 August 2015
Hong Kong Journal of Emergency Medicine
Acute epidural haematoma due to contrecoup head injury: a case report
Z Cakir, M Cakir, M Emet, S Aslan, A Saritas
Epidural haematoma (EH) is a traumatic accumulation of blood between the inner table of the skull and the dural membrane. Epidural haematoma that occurs at the opposite side of the site of injury, namely contrecoup EH, is a rare entity. We present a 56-year-old man who sustained head injury. The initial examination showed a laceration at his left frontotemporal region. Computed tomography of brain showed left frontotemporal linear fracture and right temporoparietal contrecoup EH. The EH was operated on and the patient was discharged uneventfully. Acute EH is a neurosurgical emergency, early diagnosis and prompt treatment are essential for optimal outcomes. (Hong Kong j.emerg.med. 2009;16:252-254)
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Keywords: Cranial epidural haematoma, craniocerebral trauma
Introduction Epidural haematoma (EH) is a traumatic accumulation of blood between the inner table of the skull and the dural membrane. EH may occur in 1% of patients with head injury. 1,2 It is more common in the male,
paediatric and middle-age population.3 Generally, it is located beneath a fracture. Contrecoup EH is very rare. There were only a few reports published in the literature.
Case Correspondence to: Zeynep Cakir, MD Atatürk University, School of Medicine, Department of Emergency Medicine, 25090, Erzurum, Turkey Email:
[email protected] Mucahit Emet, MD Sahin Aslan, MD Ayhan Saritas, MD Regional Educaiton and Research Hospital, Department of Neurosurgery, 25090, Erzurum, Turkey Murteza Cakir, MD
A 56-year-old man injured by an axe over the head was seen in our emergency department in February 2009. His general condition was good with a Glasgow Coma Scale (GCS) score of 15/15. He had an irregular 5 cm laceration over the left frontotemporal region. He had no loss of consciousness, amnesia or focal neurological deficit. The skull radiograph showed a left frontotemporal linear fracture. Computed tomography of brain showed right temporoparietal EH (Figure 1). The patient underwent urgent operation. He was discharged on the sixth postoperative day uneventfully.
Cakir et al./Contrecoup epidural haematoma
253
Figure 1. Computed tomography of brain showing left frontotemporal fracture and right temporoparietal epidural haematoma.
Discussion EH generally occurs following a temporoparietal linear fracture due to tear of the middle meningeal artery or its branches in the temporal fossa.2 Contrecoup EH is very rare and there are only six case reports published in the literature.4-9 The clinical features of the six cases and the present case are summarised in Table 1. All had good recovery. EH is four times more frequent in males because males are prone to trauma.1-3 However, four of the six published contrecoup EH case reports were females.4-9 Acute EH is more commonly observed in children and middle aged patients. It is rarely seen in infants and the elderly.1,2 The majority of patients with contrecoup EH were in the fifth or sixth decades. 4-9 Our patient was also in the sixth decade. Blunt head trauma is the most frequent cause of EH with a percentage range between 1-6%.10 EH is usually observed on the ipsilateral temporoparietal region of the injury. All contrecoup EHs occurred as a result of blunt parieto-occipital injuries except one case with
frontal injury by an axe.4-9 In the present case report, the patient was also injured by an axe at the frontoparietal region. Patients with EH can present with symptoms like posttraumatic amnesia, hemiparesis, pupillary dilatation, positive Babinsky reflexes and other symptoms or signs suggestive of an intracranial mass. Progressive deterioration in consciousness, depression in respiration and death may occur in patients with delayed therapy.3 Among the six contrecoup EH cases, only one was admitted to the emergency department with a GCS under 12; only four cases required surgical therapy; 7,8 and all six cases were discharged with complete recovery.4-9 Contrecoup EH is not related to main arterial injury. In two of the operated cases, it was due to the leakage of blood from dural vessels.5,6 In the other two operated cases,4,9 the bleeding might be related to the negative pressure of the trauma which sheared the dural membrane from the inner table of the skull. For the two patients without operation, the bleeding was probably not originated from major blood vessels
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Hong Kong j. emerg. med. Vol. 16(4) Oct 2009
Table 1. Summary of the clinical features of reported acute epidural haematoma caused by contrecoup injury Okamoto et al.4 (1983)
Balasubramaniam & Ramesh5 (1991)
Miyazaki et al.6 (1995)
Motohashi et al.7 (2000)
Mishra & Mohanty9 (2001)
Mitsuyama et al.8 (2004)
Present case (2009)
51, F
21, M
52, F
59, F
50, M
50, F
56, M
Fall
Fall
TA
Fall
Axe
TA
Axe
Occipital
Right parietal
Left occipital
Occipital
Left frontal
Left parietal
Left frontotemporal
Fracture
-
+
+
+
+
+
+
Coup injury
-
EH
SH
-
Contusion
EH
-
Site of contrecoup EH
Left frontal
Left frontal
Right frontal
Left frontal
Right parietal
Right frontal
Right temporoparietal
Operation for coup injury
-
+
-
-
-
+
-
Operation for contrecoup EH
+
+
+
-
+
-
+
Age, sex Cause Injury site
TA=traffic accident; EH=epidural haematoma; SH=subdural haematoma
because they resolved spontaneously in a short time interval. For our case, the contrecoup EH was operated on but no major blood vessel injury was observed. In general, acute EH is a neurosurgical emergency with high mortality. Contrecoup EH is a rare entity. Early diagnosis and prompt treatment can lead to good outcome.
References 1. 2. 3.
Rehman L, Khattak A, Naseer A, Mushtaq. Outcome of acute traumatic extradural hematoma. J Coll Physicians Surg Pak 2008;18(12):759-62. K¹ymaz N, Demir Ö, Yaz¹c¹ T, Mumcu Ç, ǹrak B. Akut Epidural Hematomlu Hastalarda Prognozu Etkileyen Faktörler. Van T¹p Dergisi 2001;8:117-9. Samudrala S, Cooper PR. Traumatic intracranial hematomas. In: Wilkins RH, Rengachary SS, editors.
Neurosurgery. 2nd ed. New York: McGraw-Hill;1996: p. 2797-807. 4. Okamoto H, Harada K, Yoshimoto H, Uozumi T. Acute epidural hematoma caused by contrecoup injury. Surg Neurol 1983;20(6):461-3. 5. Balasubramaniam V, Ramesh VG. A case of coup and contrecoup extradural hematoma. Surg Neurol 1991;36 (6):462-4. 6. Miyazaki Y, Isojima A, Takekawa M, Abe S, Sakai H, Abe T. [Frontal acute extradural hematoma due to contrecoup injury: a case report]. [Japanese] No Shinkei Geka Neurological Surgery 1995;23(10):917-20. 7. Motohashi O, Tominaga T, Shimizu H, Koshu K, Yoshimoto T. [Acute epidural hematoma caused by contrecoup injury]. [Japanese] No To Shinkei - Brain & Nerve 2000;52(9):833-6. 8. Mitsuyama T, Ide M, Kawamura H. Acute epidural hematoma caused by contrecoup head injury-case report. Neurol Med Chir (Tokyo) 2004;44(11):584-6. 9. Mishra A, Mohanty S. Contre-coup extradural haematoma: a short report. Neurol India 2001;49(1):94-5. 10. Hanc¹ M, Uzan M, Kuday C. Posterior fossa epidural hematoma. Türk Nöro irurji Dergisi 1992;3:199-201.
