0:01

Some people use the term contusion.

0:05

Synonymously with parenchymal hemorrhage.

0:08

So I make a little bit of a

0:09

distinction between the two.

0:12

So a cortical contusion, in my mind,

0:14

is sort of a brain bruise.

0:16

It has, if you will, less hemorrhage to it.

0:20

It does have hemorrhage on the susceptibility-weighted MRI scan,

0:22

but it's more edema and bruising of the

0:27

brain, whereas the intraparenchymal hemorrhage,

0:30

or what we call IPH, has more hemorrhage to it,

0:35

and it's more of a focal area of bleeding

0:39

as opposed to bruising with more vasogenic edema.

0:44

Now, the fracture and the contusion is usually

0:47

seen in the coup region, whereas the contrecoup is

0:52

more commonly an intraparenchymal hemorrhage.

0:56

So there is this

0:57

distinction that you may have a contusion

1:00

underlying where the brain was initially hit,

1:04

as opposed to the intraparenchymal hemorrhage,

1:06

which is more of a velocity-encoded injury, contrecoup.

1:12

If you have delayed presentation of an

1:16

intraparenchymal hemorrhage, that generally portends

1:19

a poor prognosis and says that this is a delayed

1:22

response, a secondary hemorrhagic involvement.

1:26

And that may be an indicator of diffuse axonal

1:30

injury, which is a more dramatic injury to the brain.

1:36

So here, for example, is a patient

1:39

who has an area of hyperdensity.

1:43

And you can see it on the image to the right as well.

1:47

This is a mixture of both edema as well as hemorrhage.

1:52

This, I would call an intraparenchymal hemorrhage.

1:55

It's got volume to it. It's got hyperdensity to it.

1:59

It does have some edema, but the edema around it

2:03

is not the dominant characteristic of this lesion.

2:07

Contrast that with this lesion.

2:10

So here we have a patient who has a low-density

2:13

area in the inferior frontal region, which does

2:16

not have that much in the way of hyperdensity to it

2:20

to suggest that it's hemorrhagic.

2:23

This is more of a parenchymal contusion.

2:27

When you're looking at patients for head trauma,

2:30

and you're looking for areas of hemorrhage in the

2:32

brain or contusion of the brain, I recommend that

2:36

you pay a lot of attention to the gyrus rectus region

2:38

along the floor of the anterior cranial fossa.

2:43

Because there is the irregularity of the

2:45

crista galli in this location that can lead to

2:49

shearing injuries of the brain on that rough

2:53

portion of the patient's anterior cranial fossa.

2:57

The other area where you may have

2:59

injury is just along the parenchyma that

3:03

abuts the greater wing of the sphenoid.

3:06

Once again, when that brain tissue is going

3:08

up against a fixed bony object, the greater

3:11

wing of the sphenoid, it will bang up against it

3:14

and cause either contusions or hematomas.

3:19

So again, coup injuries are those directly

3:22

under the point of contact of the head.

3:25

So that might be scalp,

3:27

that might be subgaleal blood products.

3:30

It's usually where the fractures occur because

3:32

of the puncture or the direct impact,

3:35

and those fractures may be open or depressed.

3:38

If they're open, in other words, open

3:40

to the outside with a laceration,

3:42

or they're depressed inward greater

3:44

than one thickness of the calvarium,

3:47

that's usually an indication for surgery.

3:49

Epidural hematomas, subdural hematomas, subarachnoid hemorrhage,

3:53

intraventricular hemorrhage, all may be coup

3:55

injuries, as well you mas see contusions.

3:59

With respect to the blood vessels

4:00

nearby, they may dissect, you may cause

4:02

a fistula, or they may cause a pseudoaneurysm.

4:04

These are all generally underlying the area where

4:07

the brain has been hit, where the head has been hit.

4:10

Contrast that with your contrecoup injuries.

4:12

Those generally are not associated with dissections,

4:16

or pseudoaneurysms, or blood vessel tearing,

4:18

but they are associated more commonly with epidural

4:21

hematomas, subdural hematomas, most of the

4:25

contusions, and most intraparenchymal hemorrhages.

4:29

Let's look at this case as an example.

4:31

Here we have the patient's area

4:35

where the scalp has been traumatized.

4:38

So this is where this patient banged their head.

4:41

Underlying that little head bang, we see a small

4:44

area of hemorrhage on the surface of the brain,

4:47

a small area of blood products in the cortex.

4:52

However, contrecoup—the opposite side—and the up—

4:58

right-to-left and the opposite side, anterior-to-

5:01

posterior, is where we see the large intraparenchymal

5:05

hemorrhage, which is actually larger than the coup

5:08

injury here, and you see it has surrounding edema.

5:14

So this is an example of coup-contrecoup

5:18

injury, with the contrecoup injury being

5:21

actually larger than the coup injury.

5:24

Here's another example.

5:26

A patient with swelling over the right temporal

5:29

region with a fracture of the calvarium,

5:34

but parenchymal contusion—contusion of

5:40

the cortex on the contralateral left side.

5:44

So this was the side where they banged their head.

5:47

But this is the side where a

5:49

parenchymal contusion has occurred.

5:52

Coup-contrecoup.

5:59

One more example: swelling of the scalp, parenchymal

6:05

hemorrhage, contrecoup swelling, and contusion here.