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Year : 2001  |  Volume : 49  |  Issue : 1  |  Page : 94-5

Contre-coup extradural haematoma : a short report.

Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221005, India.

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

  »  Abstract

An extradural haematoma contralateral to impact site is reported. Review of literature reveals that such phenomenon is extremely rare.

How to cite this article:
Mishra A, Mohanty S. Contre-coup extradural haematoma : a short report. Neurol India 2001;49:94

How to cite this URL:
Mishra A, Mohanty S. Contre-coup extradural haematoma : a short report. Neurol India [serial online] 2001 [cited 2023 Mar 31];49:94. Available from: https://www.neurologyindia.com/text.asp?2001/49/1/94/1290

   »   Introduction Top

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

   »   Case report Top

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 Top

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 Top

1.Asthana S, Mohanty S, Tandon SC et al : Extradural haematoma : Pattern in rural India. Indian Journal of Surgery 1992; 54 : 189-193.  Back to cited text no. 1    
2.Balasubramaniam V, Ramesh VG : A case of coup and contre-coup extradural haematoma. Surg Neurol 1991; 36 :462-464.  Back to cited text no. 2    
3.Hooper RS : Observation on extradural haemorrhage. Br J Surg 1959; 71-87.  Back to cited text no. 3    
4.Jamieson KG : Epidural haematoma. In hand book of clinical neurology. Vinken PJ, Bruyn GWJ (ed.). North Holland Publishing Co. 261.  Back to cited text no. 4    
5.Miyazaki et al : No Shinkei Geka 1995; 23 : 917-920.  Back to cited text no. 5    


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