40F with trauma and headache • Xray of the Week
Figure 1. What is the important finding on this CT scan.
A. Axial CT brain showing intraparenchymal hemorrhage (blue arrow) and subdural hemorrhage along tentorium (orange arrow)
B. Axial CT brain showing subdural hemorrhage along falx (yellow arrow) and coup at site of subgaleal hematoma (red arrow)
C. Coronal CT brain showing subdural hemorrhage along falx (yellow arrow) and tentorium (orange), subdural hematoma overlying left cerebral convexity (green arrows), and subgaleal hematoma at the coup (red arrows).
Contrecoup brain injury occurs when a force strikes the head and causes the brain to shift away from the site of impact, and inertia causes the brain to hit the opposite side of the intracranial cavity (1). Thus, the side of the brain opposite to the traumatic force is injured. Contrecoup brain injuries often occur in traumatic accidents where the moving brain strikes a stationary object (2). They typically occur in the frontal and temporal lobes of the brain (2,3). Contrecoup injuries are typically associated with cerebral contusions and subdural hemorrhage due to increases in intracranial pressure (2,3). In coup injuries, damage occurs on the same side of the brain as the traumatic force (2,3). Contrecoup injuries can occur with coup injuries, but they can also occur alone (2). It is important to note that coup injuries tend to be more focal and easier to identify on imaging while contrecoup injuries are diffuse and can cause more damage (1,2). The initial site of injury, or the coup site, can often be found by soft tissue swelling on CT (3,4). In this case, the coup is located at the site of the subgaleal hematoma. The contrecoup site can show hemorrhagic contusions in the frontal and temporal lobes on CT, or with MRI on Gradient echo (GRE) sequences (3). The contrecoup site can also present with subdural hematomas (SDH) along the falx and tentorium as in this case. Patients require thorough neurological examination and imaging including head CT scan and cervical X-rays or CT scan, especially in falls (2).
Treatment depends on the severity of the injury and presence of other injuries, but typically involves surgical decompression, evacuation of hematoma, or lobectomy (2). Patients with neurological deficits and Glasgow coma score less than 9 require intracranial pressure monitoring (2,4). Follow up head CT at 12 hours is recommended (2).
1. Salyer, Steven W. “Care of the Multiple Trauma Patient.” Essential Emergency Medicine, Elsevier, 2007, pp. 1050–112. doi:10.1016/B978-141602971-7.10018-2
2. Payne WN, De Jesus O, Payne AN. Contrecoup Brain Injury. [Updated 2020 Jun 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK536965/
3. Kim JJ, Gean AD. Imaging for the Diagnosis and Management of Traumatic Brain Injury. Neurotherapeutics 8, 39–53 (2011). doi:10.1007/s13311-010-0003-3
4. Le TH, Gean AD. Imaging of head trauma. Semin Roentgenol. 2006;41(3):177-189. doi:10.1053/j.ro.2006.04.003
Amara Ahmed is a medical student at the Florida State University College of Medicine. She serves on the executive board of the American Medical Women’s Association and Humanities and Medicine. She is also an editor of HEAL: Humanism Evolving through Arts and Literature, a creative arts journal at the medical school. Prior to attending medical school, she graduated summa cum laude from the Honors Medical Scholars program at Florida State University where she completed her undergraduate studies in exercise physiology, biology, and chemistry. In her free time, she enjoys reading, writing, and spending time with family and friends.
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Kevin M. Rice, MD is the president of Global Radiology CME
Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.
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