Francis Thomas, Chakrabarti Dhritiman, K Sarina, George Ivy
Department of Neuroanesthesiology and Neurocritical Care, National Institute of Mental Health and Neurosciences, Bengaluru, IND.
Cureus. 2025 Jul 31;17(7):e89141. doi: 10.7759/cureus.89141. eCollection 2025 Jul.
A 38-year-old man sustained a traumatic brain injury (TBI) following a road traffic accident, presenting unconscious with vomiting and right ear bleeding. He had a prior history of head trauma with cranioplasty. On admission, he was deeply unconscious (Glasgow Coma Scale (GCS) E1VTM3) with unequal non-reactive pupils. Imaging revealed a significant left-sided acute subdural hematoma (SDH), burst temporal lobe, and midline shift, alongside an old cranioplasty mesh and right petrous bone fracture. Notably, there was minimal injury on the right (impact) side but extensive hemorrhagic damage on the left (opposite) side, suggesting a contrecoup injury. He underwent emergency decompressive craniotomy and postoperative ICU care, eventually recovering enough for discharge. This case highlights an unusual presentation of contrecoup injury in the absence of significant coup-related hemorrhage. The presence of a cranioplasty mesh likely influenced injury mechanics. The proposed mechanism involves both positive and negative pressure theories: the brain lagging behind skull motion (positive pressure) and rebound forces (negative pressure), creating damage on the opposite side. The mesh's rigidity compared to natural bone may have amplified injury through stress concentration at the mesh-bone interface. This unique biomechanical interaction may explain the disproportionate injury seen contralaterally. To our knowledge, no previous case reports describe such an isolated contrecoup injury pattern associated with a cranioplasty mesh. This report underscores the importance of considering altered skull biomechanics in patients with prior cranial surgeries and contributes novel insight into TBI dynamics.
一名38岁男性在道路交通事故后遭受创伤性脑损伤（TBI），表现为昏迷、呕吐和右耳出血。他既往有头部外伤并接受过颅骨成形术的病史。入院时，他深度昏迷（格拉斯哥昏迷量表（GCS）E1VTM3），双侧瞳孔不等大且无反应。影像学检查显示左侧有大量急性硬膜下血肿（SDH）、颞叶破裂和中线移位，同时还有一个旧的颅骨成形术网片和右侧岩骨骨折。值得注意的是，右侧（撞击侧）损伤轻微，但左侧（对侧）有广泛的出血性损伤，提示为对冲伤。他接受了紧急减压开颅手术和术后重症监护病房护理，最终恢复到足以出院。该病例突出了在无明显对冲相关出血情况下对冲伤的不寻常表现。颅骨成形术网片的存在可能影响了损伤机制。提出的机制涉及正压和负压理论：大脑滞后于颅骨运动（正压）和反弹力（负压），在对侧造成损伤。与天然骨相比，网片的刚性可能通过网片 - 骨界面处的应力集中放大了损伤。这种独特的生物力学相互作用可能解释了对侧出现的不成比例的损伤。据我们所知，以前没有病例报告描述过与颅骨成形术网片相关的这种孤立的对冲伤模式。本报告强调了在有既往颅脑手术史的患者中考虑颅骨生物力学改变的重要性，并为TBI动力学提供了新的见解。
