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Year : 2017  |  Volume : 10  |  Issue : 3  |  Page : 321-322  

Revisiting the contrecoup extradural hematoma

Department of Neurosurgery, KGMU, Lucknow, Uttar Pradesh, India

Date of Web Publication19-May-2017

Correspondence Address:
Sushanta Kumar Sahoo
Department of Neurosurgery, KGMU, Lucknow - 226 003, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-2870.206581

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How to cite this article:
Sahoo SK, Srivastava C, Vankipuram S. Revisiting the contrecoup extradural hematoma. Med J DY Patil Univ 2017;10:321-2

How to cite this URL:
Sahoo SK, Srivastava C, Vankipuram S. Revisiting the contrecoup extradural hematoma. Med J DY Patil Univ [serial online] 2017 [cited 2022 Aug 7];10:321-2. Available from:


Extradural hematoma (EDH) is among one of the common presentations in head injury. It is usually located at the site of impact due to separation of the dura mater from the inner calvaria. However, EDH at the contrecoup site is very unusual.[1] We are reporting here a case of head injury with EDH at both the site of impact and contrecoup site with review of underlying mechanism for contrecoup EDH.

A 22-year-old male presented to our casualty following a road traffic accident. He fell from a two wheeler and his right side of head hit the ground without any second impact. At the time of presentation, the patient was conscious but irritable (Glasgow Coma Scale = E4V4M6). There was scalp hematoma at the right frontal region. Computed tomography scan showed EDH of size approximately 35cc on right frontal area, 20cc on left temporal area, and right temporal contusion with right to left midline shift [Figure 1]a and [Figure 1]b. In view of temporal contusion, bilateral EDH was evacuated [Figure 1]c and the patient put on decongestants (intravenous mannitol). The patient improved completely and discharged on 6th postoperative day.
Figure 1: (a) Noncontrast computed tomography scan showing coup right frontal extradural hematoma and left temporal contrecoup extradural hematoma. (b) Note the right temporal contusion. (c) postoperative image showing complete evacuation of extradural hematoma at the coup and contrecoup site

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Deformity of the less elastic skull bone or fracture at the site of impact may strip of the dura from the inner calvarium.[1] Branches of meningeal artery present between these layers often injured and the blood accumulated in the extradural space may further separate the dura from the bone. The dura is relatively less adherent at the temporal region and also the thin squamous temporal bone is more prone for fracture, responsible for the common location of EDH at this site.[2] However, mechanism for EDH other than the site of impact is not clear.

Cavitation effect and inertia loading have been described as the pathogenic mechanisms for contusion at the contrecoup site. The negative pressure generated opposite to the site of impact may create cavitation. On the other hand, the tensile strain produced in an angular head movement may cause vascular injury.[3] Both of them explain the contrecoup intraparenchymal injury. However, contrecoup EDH is difficult to understand by these phenomena. Balasubramaniam and Ramesh have proposed that EDH can occur due to buckling effect of the skull exactly opposite to the site of impact.[4] Some also suggested that the negative pressure created at the contrecoup site will strip off the dura if it is loosely adhered to the inner calvaria.[1] We believe that because of the compression wave from the site of impact to the diagonally opposite side produced a relative movement between the dura and the skull bone at the left temporal region is responsible for contrecoup EDH in our case. Again, a rotational component to the head injury may have stripped off the dura from the uneven skull surfaces such as lesser wing of the sphenoid or the petrous bone if it is less adherent.

Only few cases of contrecoup EDH have been reported in literature. The proposed theories for contrecoup head injury do not address to the formation of EDH at these sites. Therefore, contrecoup EDH may be considered as a distinctly different entity.

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There are no conflicts of interest.

  References Top

Mitsuyama T, Ide M, Kawamura H. Acute epidural hematoma caused by contrecoup head injury – Case report. Neurol Med Chir (Tokyo) 2004;44:584-6.  Back to cited text no. 1
McLaurin RL, Ford LE. Extradural hematoma. J Neurosurg 1964;21:364-71.  Back to cited text no. 2
Meaney DF, Olvey SE, Gennarelli TA. Biomechanical basis of traumatic brain injury. In: Winn HR, editor. Youmans Neurological Surgery. 6th ed., Vol. 4. Philadelphia: WB Saunders; 2011. p. 3284-5.  Back to cited text no. 3
Balasubramaniam V, Ramesh VG. A case of coup and contrecoup extradural hematoma. Surg Neurol 1991;36:462-4.  Back to cited text no. 4


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