Acute contrecoup epidural hematoma that developed without skull fracture in two adults: two case reports

Pediatric acute epidural hematoma caused by contrecoup injury: illustrative case

BACKGROUND

Acute epidural hematomas (AEDHs) are formed by injury of the middle meningeal artery or venous sinus with a linear fracture just above these blood vessels. The incidence of AEDH without fracture is low, and the formation of an acute epidural hematoma due to contrecoup injury is even rarer. Here, the authors report a case of pediatric AEDH due to contrecoup injury.

OBSERVATIONS

A 6-year-old boy was injured in a traffic accident and was ejected from of the car. At admission, he was clearly conscious without obvious neurological deficits. Computed tomography (CT) revealed a small fracture in the right occipital lobe and a thin epidural hematoma in the contralateral left frontal lobe. A CT scan 3 hours later showed an expanded AEDH. Furthermore, the patient presented with progressive disturbance of consciousness. An emergency craniotomy was performed, but no obvious bleeding point or fracture was observed.

LESSONS

The source of bleeding in AEDH due to contrecoup injury in the frontal region is thought to be due to microvessel injury in the dura. Anatomical fragility and the amount of energy transferred causing the injury are associated with the AEDH formation due to contrecoup injury; thus, strict management in high-energy trauma is required.

Contrecoup Injury-Induced Middle Meningeal Arteriovenous Fistula Detected by Time-of-Flight Magnetic Resonance Angiography and Magnetic Resonance Arterial Spin Labeling: Case Report and Review of the Literature

BACKGROUND

Middle meningeal arteriovenous fistula (MM-AVF) is rare; however, it will sometimes be followed by intracranial hemorrhage or progressive symptoms caused by abnormal shunt flow. Radiological examination and endovascular treatment of this condition have recently advanced; thus, we have described the pathogenesis, clinical features, and appropriate diagnostic and therapeutic management of MM-AVF. We also reviewed the reported data of the past 35 years, including 30 cases of MM-AVF.

CASE DESCRIPTION

We report the case of 24-year-old man who had presented with right tinnitus who had experienced previous head trauma on the opposite side to the tinnitus ear. Time-of-flight magnetic resonance angiography and magnetic resonance arterial spin labeling findings were suggestive of MM-AVF, and catheter angiography confirmed MM-AVF with shunt flow draining into the cavernous sinus. Endovascular transarterial embolization was performed, and the MM-AVF was embolized successfully using detachable coils and n-butyl-2-cyanoacrylate. The tinnitus disappeared completely immediately after the treatment.

CONCLUSIONS

MM-AVF is caused, not only by coup injury, but also by contrecoup injury. Time-of-flight magnetic resonance angiography and magnetic resonance arterial spin labeling are useful for detecting MM-AVF. Endovascular transarterial embolization is an effective and safe treatment.

Contrecoup Extradural Hematoma Without Fracture: A Case Report and Review of Literature

Extradural hemorrhages are commonly seen in coup head injuries, rarely seen in contrecoup head injuries. Acute extradural hemorrhage in the coup head injuries associated with a fracture is common, but the incidence of acute contrecoup extradural hemorrhage not associated with the fracture is extremely rare. Only 21 cases have been reported previously. A 28-year-old male patient presented to the emergency department with complaints of sustaining injuries in a road traffic accident by fall from a two-wheeler. No history of loss of consciousness, vomiting, seizures, and ear/nose bleed. On examination, the patient was conscious and coherent with a Glasgow Coma Scale score of 15/15 and a laceration on the right frontotemporal region which was sutured. Contrast tomography of the brain revealed an extradural hemorrhage of 10 mm thickness in the left parieto-occipital region with soft tissue swelling in the right temporoparietal region, without any evident fractures in the calvarium. The patient was managed conservatively. Contrecoup extradural hematoma is a rare entity, and those without fracture are extremely rare. Early diagnosis, careful observation, and management lead to a good outcome.