Contrecoup Lesions Research Articles

Where is the contre-coup? Atypical localization of occipital brain contusion

Abstract Most traumatic brain injuries with occipital impact cause frontal and temporal contre-coup lesions, while patients with coagulopathies are more susceptible to such lesions. We present the case of a chronic ethylic patient with thrombocytopenia, who was treated for ethanol withdrawal syndrome at a psychiatric service. The head CT scan revealed an occipital contusion with atypical localization and the absence of fronto-temporal contre-coup lesions. In conclusion, it is recommended a head CT scan to chronic alcoholic patients with psychiatric manifestations, especially in the context of systemic coagulopathies related to excessive alcohol consumption. In the case of chronic ethylic patients that frequently display systemic coagulation disorders, the head CT scan is necessary at the first psychiatric manifestations.

Cardiothoracic Contrecoup and Contralateral Injuries: Nomenclature, Mechanism, and Significance

Objective: Contrecoup injuries are well-known lesions in the neurosurgical practice, while their existence in other medical disciplines is lacking. Another term of confusion is the contralateral lesion that is ill defined when compared to the contrecoup injury. A nomenclature, mechanism, and clinical significance of such lesions in cardiothoracic trauma patients are warranted. Patients and Methods: Only one patient with thoracic contracoup injuries was found in a retrospective review of 477 patients with significant cardiothoracic trauma managed during a 10-year period, between January 1988 and December 1997, at Sahlgrenska University Hospital/Ostra, Gothenburg, Sweden. The other four cases with contrecoup injuries were encountered in a prospective manner in different places both in Sweden and Norway. All the four prospective cases were witnessed and well documented during trauma occurrence and management. Results: All patients developed significant contralateral chest wall symptoms and signs requiring treatment. One patient developed huge contrecoup pneumothorax. Two patients developed contrecoup hemothoraces. One patient developed contrecoup cardiac injury. One patient developed contralateral chest wall rib fractures. Two patients developed contralateral sternal fractures; one of them was unstable and required surgical fixation. Conclusions: Nomenclatures to what are have called contrecoup and contralateral lesions in cardiothoracic practice are suggested. Discrepancy between the trauma side of the chest and the resulting lesions exactly on the contralateral part may make the diagnosis difficult to understand and could give a suspicion concerning the trauma site, and whether the patient was conscious or simply not telling the truth as in case of trauma with medicolegal aspects.

Edwin Smith Papyrus Case 8: a reappraisal

There are 3 translations of the Edwin Smith Papyrus: Breasted's (1930), Allen's (2005), and Sanchez and Meltzer's (2012). Case 8 is similarly presented in all 3 translations, although with increasing detail in the later works. The patient in Case 8 had a comminuted skull fracture under intact skin. There were palpable pulsations at the fracture site. There was deviation of the eye on the side of the injury and an ipsilateral spastic hemiparesis in an ambulant patient with bleeding from the nose and ear. Explanations of the paralysis have included a contrecoup lesion and compression of the contralateral cerebral peduncle against the tentorial incisura. Brainstem compression due to herniation is accompanied by loss of consciousness. Extensive contrecoup lesions consistent with the extent of the described paresis would also be associated with probable coma. The paralysis was spastic, but spasticity takes weeks to develop after trauma. Yet this patient's trauma was fresh, as there was still bleeding from the nose and the ear. It is suggested the paresis antedated the trauma, which was not its cause. The reasons for this suggestion are presented in this paper.

Significance of Contre-Coup Injury in Trauma to Brain for Concluding Manner of Death: A Case Report

Traumatic brain injury is defined as an alteration in the brain function, or other evidence of brain pathology, caused by an external force. Injuries to brain can be classified as those occurring due to primary damage and secondary damage. Primary damage is that occurs at the time of actual impact. There are multiple types of primary damages that may occur. These include: skull fracturebreaking of skull bone, contusion/bruise, hematoma/blood clot, laceration, and nerve damage (diffuse axonal injury). While secondary damage is the damage that occurs over time after the actual brain injury; may include infection, hypoxia (oxygen deprivation), edema (brain swelling), elevated intracranial pressure, infraction (death of brain tissue which results in loss of blood supply to that region of the brain) and hematoma (focal area of bleeding in the skull due to tearing of blood vessels). When one considers the various types of intracranial lesion produced by trauma to the head, there is one type of injury which excites much speculation as to the application in solving medico legal cases, namely, contre-coup injury a type included in closed head injury. Coup contre-coup injury describes contusions that are both at the site of the impact and on the complete opposite side of the organ. This occurs when the force impacting is not only great enough to cause a contusion at the site of impact, but also is able to move the organ and cause it to slam into the opposite side of the hard protective wall of the organ, which causes the additional contusion. It can be seen in brain, heart[1], spleen and lungs[2,3]. Commonly, it is seen in brain. In most head injuries - notably traffic accidents and falls-there is marked deceleration of the moving head on contact with a fixed surface, though there might still be a ‘coup’ lesion at the site of impact, there is often cortical damage on the opposite side of the brain-the ‘contre-coup’ lesion[4]. Practical points to be considered are - there may be no coup damage at all, only contre-coup. There need be no fracture of skull, even in the presence of severe coup and contrecoup lesions. The most common site for contre-coup injury is in the frontal and temporal lobes. It is often at the tips and on the undersurface of these lobes, and may be symmetrical, if a fall on the occiput has occurred. In temporal or parietal impacts, the contre-coup lesions are on contralateral regions but exact geometrical correspondence is not necessary[5]. Few authors opine that in absence of other injuries to head and brain contre-coup injury is most dangerous. The authors describe here a case where the understanding of coup and contre-coup injury helped in solving the case and administration of justice.

Frequency, types and causes of intraventricular haemorrhage in lethal blunt head injuries

Autopsy findings and neuropathological examination of formalin-fixed brains in 676 deaths due to blunt head injury, here with special attention to injuries of the inner (periventricular) cerebral structures and haemorrhages into the ventricles. Intraventricular haemorrhage of any degree was present in 17.6%, considering only distinct and massive haemorrhage in 10% of all cases. Considering the types of trauma, the frequency was lowest in ground level falls and highest in traffic accidents (pedestrians with head contact to the car) – indicating a relation between the severity of impacts and the likelihood of ventricular haemorrhage. They predominantly resulted from periventricular injuries (27%) or retrograde expansions of infratentorial lesion with subarachnoid bleeding (19%), from massive contrecoup lesions (14%) or deep intracerebral ruptures (13%). In cases with predominant lesions of the cerebral surface the rate was lower than in those with more diffuse or internal damages. Injuries of the internal cerebral regions (away from cortex and subcortical white matter) were classified into those directly affecting the periventricular structures (9.1–13.5%; half of them affecting corpus callosum and/or fornix) and lesions of deep white matter or basal ganglia not adjoining the ventricular walls (4.0–5.9%). Intraventricular haemorrhage as well as injuries of the inner cerebral structures mostly are one element of a complex and severe blunt head injury. Solitary lesions – without other intracranial findings clearly indicating a trauma and therefore cases producing difficulties in forensic classification (spontaneous? traumatic?) – are rarities according to literature as well as our experiences.

Experimental brain damage from fluid pressures due to impact acceleration. 3. Morphological observations.

"Contre-coup" lesions occurring particularly in the frontal and temporal lobes following head injury have been claimed to be caused by sudden negative pressure transients, as part of the "contre-coup" end pressures occurring in the brain tissue at an occipital impact. With a new experimental model such impact acceleration pressure (near-1 atm) could be generated in the rabbit brain through a parietal opening. Resulting morphological changes were evaluated with various microscopical methods, including Evan's blue-albumin technique for observations on vascular permeability changes. Regardless of the magnitude of the negative pressure transients no changes characteristic of "contre-coup" lesions were seen in temporal lobes, i.e. in areas where preparative artefacts are absent in control animals. Therefore such negative pressure transients per se do not appear to be of major importance for the development of contre-coup lesions. However, vascular permeability changes were frequently observed in the brain stem and upper cervical cord and are presumably related to the flow of tissue in the cranio-spinal junction.

Diabetic artefacts in forensic practice

A case is presented where confusion arose about skin lesions and whether they were diabetic or electrical in origin. The deceased was a known diabetic and hypertensive man. A middle-aged person in early fifties was found unconscious in the cell and judicial autopsy was performed. He was facing trial for capital punishment of being allegedly involved in drug trafficking and money laundering. He had few marks over his fingers and foot which were considered to be electric marks produced in electric torture. also had fracture of skull and ischemic necrosis of right side of cerebrum; and contrecoup lesions. Findings are documented with photographs of the lesions. The article also depicts photographs of the scene where the victim had fallen and sustained skull fracture.

The use of clinical CCT images in the forensic examination of closed head injuries

The forensic evaluation of clinical cranial computed tomographies (CCT) frequently is the only reliable source of morphological evidence in head injuries when the injured individual survives or when death is delayed and autopsy findings are characterized by secondary changes. We have reviewed 21 cases where clinical CCT examinations were used to establish a medico-legal diagnosis. In 18 cases falls ( n=13) could be distinguished from blows ( n=5) due to the presence and/or absence of coup and contrecoup lesions and linear or depressed skull fractures. In two cases the striking object could be identified by digital superimposition. The minimum number of blows could be determined in 1 case. Only in 3 remaining cases the results were inconclusive. In our experience, CCT scans provide an important source of information for the forensic expert. To have unbiased access to these information, it is useful to evaluate the CT scans personally which requires a basic knowledge of traumatic changes found on radiographs.

반충손상을 동반한 측두골 골절

In patients with a blow to the head or a fall into the head, contre-coup injury occurred in the contralateral side of impact with temporal bone fracture. The involved area of the temporal bone fracture was confirmed with computerized tomography(CT), and the contre-coup injury was also recognized with CT or magnetic resonance imaging(MRI). Contre-coup lesions appeared with the patterns of meningeal edema in middle cranial fossa, subdural hematoma in the temporo-parietal area, cerebral hemorrhagic contusion in anterior cranial fossa. It could be concluded that MRI is very useful in the detection of the intracranial lesions unrecognizable in CT, and especially in the temporal bone fracture patients complaining of headache.

Paediatric head trauma: influence of age and sex. II. Biomechanical and anatomo-clinical correlations.

A consecutive, unselected series of 1812 cases of head trauma in children less than 15 years of age and admitted hospital over a period of 8.5 years was studied. Data concerning the grade of energy involved, the ages of the victims, the types of pathologies caused and the clinical features noted were collected and statistically analysed. Babies and toddlers (0-3 years) were shown to sustain rather low-energy trauma and suffer more skull fractures, more subdural haematomas and more benign injuries. They lost consciousness less frequently and were less frequently in coma than the other children. By contrast, they had more frequent signs of lateralization, and early seizures were much more frequent in babies than in other children. Young children (3-9 years) had rather higher-energy accidents, frequently lost consciousness, were more frequently in coma and have more frequently had a free interval associated with the development of brain swelling. They did not suffer subdural effusion or contrecoup lesions. Schoolchildren (9-15 years) were statistically more or less like young adults: the clinical sequences of trauma were more severe than in the other children, mortality was a little bit higher, the risk of extradural haematoma was higher, and they rarely suffered subdural haematomas or contrecoup lesions. Traffic accidents, with higher energy involved, were more severe.

Differences in the intracranial pressure caused by a ‘blow’ and/or a ‘fall’ — An experimental study using physical models of the head and neck

In cases of a severe head injury caused by a fall, coup contusions are either absent or very minor, in contrast to presence of extensive contre-coup damage. In cases of a severe blow to a head, however, the reverse occurs, with contre-coup lesions a rarity and coup damage extensive. To investigate this further, head injuries caused by a ‘blow’ or a ‘fall’ have been studied, using physical human models of the head and neck, both filled with distilled, degassed water and fixed onto a dummy torso. An impact of a constant magnitude was applied to the midoccipital region in ‘blow’ and ‘fall’ experiments, and the acceleration of the head and changes in the intracranial pressure were measured, with the resulting data analyzed by a computer. In both experiments, the peak amplitude of the acceleration pulse were almost the same. Similarly, the intracranial pressure curve at the impact site consisted of a positive pulse that hardly differed, nor did the peak amplitude of that pulse vary significantly. In the ‘blow’ experiment, however, the intracranial pressure curve at the site opposite the impact consisted of a negative pulse, whereas in the ‘fall’ experiment, the intracranial pressure recorded at the same area was negative but of a longer duration, with an absolute value that was slightly greater. Our results indicate that an impact to the head triggers a different response in the intracranial space, dependent on whether that impact force was caused by a ‘blow’ or a ‘fall’.

Temporal lobe lesions in head injury.

In cases of closed head injury temporal lobe lesions e.g. contusion, laceration, pulping, or intracerebral haematoma frequently result in an expanding process. These are frequently associated with an overlying subdural haematoma. Eighty five cases of such lesions from a consecutive series of 1,000 cases of head injury have been analyzed. The lesions are caused by severe injury resulting in loss of consciousness and skull fracture. Most of them are contre-coup lesions. Clinically they manifest themselves like any other acute or subacute intracranial hematoma. The majority of the patients have contralateral hemiparesis and pupillary abnormalities. Carotid angiography is valuable for diagnosis. These lesions are likely to be missed when exploratory burr holes are made or, are erroneously diagnosed as acute subdural haematoma or brain oedema. Smaller lesions, not showing progressive deterioration, may respond to conservative treatment. However, surgical decompression is essential in most cases A frontotemporal osteoplastic craniotomy or a large Scoville trephine hole is essential to deal with these lesions adequately.

Contrecoup Injuries of the Brain in Infancy

THE TERM has long been associated with the mechanism of craniocerebral injury. Its first use was in reference to the occurrence of fracture by Hippocrates,1in which a linear fracture appears opposite the point of a traumatic impact. It was used in this sense from the 16th to the 19th centuries.2It is not clear exactly when the term was applied to soft tissue contusions, but contrecoup lesions were the subject of numerous contributions by French surgeons during the middle of the 18th century.3Here the matter rested until the early 20th century when the treatise of Le Count and Apfelbach4on automobile injuries of the head and brain again called attention to the subject. This principle of as it concerns the mechanism of cerebral contusions has been used by the writer in several contributions.5-10In accord with the observations of Le

Contrecoup Lesions in the Relatively Severe Craniocerebral Injuries

Contrecoup Lesions in the Relatively Severe Craniocerebral Injuries

The Minor Sequelae of Eye Contusions

To test the validity of the late Henri Frenkel's notion of the anterior-segment traumatic syndrome, thirty-four consecutive eye contusions were tabulated with reference to sequelae in cornea, pupillary reflexes, iris, lens, vitreous, fundus, and visual acuity. Dehiscences of the retinal layer of the iris were found by slitlamp diapupillary transillumination in the fundus reflex in half of the cases, and so frequently related topographically to the lens and peripheral fundus sequelae as to justify Frenkel's syndrome theory, and to support his thesis of the active role of the subluxated lens in the production of the syndrome. The effect of the anterior-segment lesions on visual acuity, when the media are clear, is due, however, to easily overlooked posterior-pole contrecoup lesions generally.