Contrecoup Extradural Hematoma: When Hematomas Do Not Follow Rules

Extradural hematoma (EDH) is a fairly common entity in neurosurgical practice but EDHt at a contrecoup site and crossing a cranial suture is rare. The authors present a case of EDH due to contrecoup injury in whom sutural diastases was noted and hematoma was seen to be crossing the adjacent suture. This was accompanied with subdural hematoma (SDH) at the coup site. According to the best of our knowledge, it makes the case only the 13(th) such to be reported in adults. A 27-year-old male patient was brought by relatives with a history of fall from a height resulting in head trauma over the left posterior parietal region. The patient presented with headache at the site of impact. Computed tomography (CT) scan of the brain revealed an undisplaced fracture of parietal bone on the left side (coup site) along with a small concavo-convex hyperdense lesion suggestive of a SDH. Scan also revealed a large biconvex, hyperdense lesion in the right frontoparietal region (contrecoup site). The hematoma was seen to be evidently crossing the coronal suture. Sutural diastases of coronal suture was suspected and the same was noticed intraoperatively. Approximately 80cc of clot was removed and hemostasis was achieved through coagulation of the middle meningeal artery and via dural hitch sutures. Contrecoup EDH across the adjacent suture with sutural diastases is rare as it does not follow the set rules of hematomas. A high index of suspicion is central in arriving at a rapid diagnosis and an early surgery to achieve a favorable outcome. The authors recommend a CT scan along all three planes along with a three-dimensional reconstruction for ready diagnosis. Contrecoup EDH with sutural diastases is a distinct and potentially dangerous entity and neurosurgeons should be aware of the same.