Authors: Francis T, Chakrabarti D, K S, et al.
Cureus 17(7): e89141. doi:10.7759/cureus.89141
This case report describes a 38-year-old man who sustained a traumatic brain injury (TBI) following a road traffic accident, presenting with unconsciousness, vomiting, and right ear bleeding. Despite having an impact injury on the right side (petrous bone fracture), imaging revealed a large left-sided acute subdural hematoma (SDH), burst temporal lobe, and significant midline shift. Notably, the left side had a prior cranioplasty with a titanium mesh from an earlier head injury. The absence of substantial hemorrhage at the site of impact and the presence of extensive contralateral damage led to the diagnosis of an isolated contrecoup injury. The patient underwent emergency decompressive craniotomy and recovered sufficiently for discharge.
Cranial computed tomography (CT) showed a left frontotemporoparietal thick acute SDH with temporal lobe involvement and a midline shift of 1.5 cm to the right side. Also, an old cranioplasty mesh was seen on the left frontotemporoparietal side with left frontal gliosis. Bone-window CT with 5 mm slice thickness demonstrated a visible fracture in the right petrous bone with overlying air pockets seen in the subcutaneous tissue (Figure 1).
The report proposes that the cranioplasty mesh altered intracranial force dynamics during trauma, amplifying the contralateral injury through mechanisms explained by both positive pressure (brain lagging behind skull motion) and negative pressure (rebound forces). The rigidity of the mesh, in contrast to natural bone, may have concentrated stress at the mesh-bone interface, worsening injury severity. Additionally, penetrating screws used in mesh fixation might have contributed to parenchymal and vascular damage. To the authors’ knowledge, this is the first case documenting an isolated contrecoup injury associated with a cranioplasty mesh.
This case emphasizes the need to consider altered skull biomechanics in patients with prior cranial surgeries when evaluating trauma. Rapid stabilization, urgent imaging, decompressive craniotomy, and vigilant ICU care are critical in managing such injuries. Long-term care should address potential complications related to implanted materials.
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