Contrecoup Brain Injury

40F with trauma and headache • Xray of the Week

Figure 1. What is the important finding on this CT scan.

Figure 2.

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).

Discussion:

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 often 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 may rarely 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 hematoma (SDH) along the falx and tentorium as in this case.

Treatment depends on the severity of the injury and presence of other injuries, but typically involves surgical decompression and evacuation of hematoma (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).

References:

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.

Follow Amara Ahmed on Twitter @Amara_S98

UPDATE: Dr. Ahmed will be a radiology resident at University of Florida in 2024.

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Kevin M. Rice, MD is the president of Global Radiology CME and is a radiologist with Cape Radiology Group. He has held several leadership positions including Board Member and 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. He was once again a semifinalist for a "Minnie" for 2021's Most Effective Radiology Educator by AuntMinnie.com. He has continued to teach by mentoring medical students interested in radiology. Everyone who he has mentored has been accepted into top programs across the country including Harvard, UC San Diego, Northwestern, Vanderbilt, and Thomas Jefferson.

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