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Contre-coup extradural haematoma : a short report.
Correspondence Address:
An extradural haematoma contralateral to impact site is reported. Review of literature reveals that such phenomenon is extremely rare.
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.
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.
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.
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