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Year : 2016  |  Volume : 23  |  Issue : 1  |  Page : 52-53

The “CT Comma Sign” in concurrent extradural and hyperacute subdural hematomas is revisited

1 Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India
2 Department of Radiology, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India

Date of Web Publication6-Jan-2016

Correspondence Address:
Amit Agrawal
Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore - 524 003, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1115-3474.155748

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How to cite this article:
Agrawal A, Hegde KV, Reddy V U. The “CT Comma Sign” in concurrent extradural and hyperacute subdural hematomas is revisited. West Afr J Radiol 2016;23:52-3

How to cite this URL:
Agrawal A, Hegde KV, Reddy V U. The “CT Comma Sign” in concurrent extradural and hyperacute subdural hematomas is revisited. West Afr J Radiol [serial online] 2016 [cited 2023 Sep 24];23:52-3. Available from: https://www.wajradiology.org/text.asp?2016/23/1/52/155748

Extradual hematoma (EDH) is the collection of blood between the inner skull table and dura, and appears as a biconvex-lens shape on imaging.[1],[2] In comparison to EDH, the subdural hematoma (SDH) is a collection of blood between the dura and arachnoid membrane and it has a biconcave-lens shape on imaging.[1],[3] In the acute stage, most of these hematomas present as hyperdense lesions on computerized tomography (CT) images.[1],[2],[3],[4] In rare circumstances, a patient can have acute extradural hematoma and subdural hematoma adjacent to each other on the same side with a characteristic imaging appearance.[5],[6]

A 26-year-old male patient sustained head injury in a road traffic accident and presented 6 hours after to the emergency department. The patient was unconscious from the time of injury and had multiple episodes of vomiting. There was no history of seizures or nasal/ear bleeds. His general and systemic examination was unremarkable. Neurologically, he had altered sensorium [Glasgow coma score (GCS)-E1V2M5]. Pupils were bilaterally equal and reactive to light. He moved all four limbs normally. He had multiple abrasions over face and scalp.

The non-contrast CT scan of the brain with bone windows showed a biconcave mild hyperdense collection extending all over the right fronto-temporo-parietal region and a hyperdense biconvex lesion just behind this collection over the right parieto-occipital region with associated small bi-frontal polar contusions [Figure 1]. There was significant mass effect and midline shift, but no fracture was noted. Blood investigations including coagulation profile were normal. The patient underwent right fronto-temporo-parietal craniotomy.
Figure 1: CT scan brain showing convaco-convex mild hyperdense collection extending all over the right fronto-temporo-parietal region and a hyperdense biconvex lesion over right parieto-occipital region and associated small bifrontal polar contusions (inset please note “CT comma sign”), right image showing schematic representation of the “CT coma sign” (upper arrow depicting SDH and lower arrow depicting EDH)

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At surgery, there was an extradural hematoma in the parieto-occipital region that was evacuated. The dura was tense and non-pulsatile. After the dura was opened, there was another hemorrhagic collection that was mixed with clots and CSF which was also evacuated. Following evacuation, the brain was lax and pulsatile. After achieving hemostasis, the wound was closed in layers. The patient improved significantly after surgery and the GCS was E4V4M6. Follow-up images showed complete evacuation of the hematomas [Figure 2]. There were no focal deficits.
Figure 2: Follow-up CT scan showing complete evacuation of EDH and SDH

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There are only few case reports in the literature where concurrent extradural and SDHs have been reported.[7],[8],[9],[10] The underlying mechanisms described for these lesions are underlying fracture and associated extradural hematoma (coup injury) and acute SDH may be the manifestation of contrecoup injury (as we saw in the present case).[5],[6],[11] Monsalve [6] has discussed the appearance of such lesions in details and described the typical appearance as “CT comma sign.” We need to remember that a classical “CT comma sign” will appear only when there is a left-sided lesion (EDH in the frontal region and SDH is posterior to the EDH);[6] however, if the skull is imagined as a circle, then the comma rotates in a circle [Figure 1]. The author further suggested that when there is a finding of the “CT comma sign” the neurosurgeons and radiologists should be cautious as there may be two extra-axial hemorrhagic lesions, that is, extradural and SDHs.[6] Surgical evacuation is the treatment of choice with good outcome for larger hematomas.[6],[12],[13],[14],[15] The outcome is determined by the neurological status at the time of presentation, size of hematoma and associated underlying brain injury (e.g. PCA infarct, etc.).[5],[13],[14],[15],[16]

  References Top

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Klufas RA, Hsu L, Patel MR, Schwartz RB. Unusual manifestations of head trauma. AJR Am J Roentgenol 1996;166:675-81.  Back to cited text no. 2
Merino-deVillasante J, Taveras JM. Computerized tomography (CT) in acute head trauma. AJR Am J Roentgenol 1976;126:765-78.  Back to cited text no. 3
Besenski N. Traumatic injuries: Imaging of head injuries. Eur Radiol 2002;12:1237-52.  Back to cited text no. 4
Gupta R, Mohindra S, Verma SK. Traumatic ipsilateral acute extradural and subdural hematoma. Indian J Neurotrauma 2008;5:113-4.  Back to cited text no. 5
Monsalve GA. The” CT comma sign” in head trauma: Concurrent epidural and subdural acute intracranial hematomas. J Trauma Acute Care Surg 2007;63:195-6.  Back to cited text no. 6
Baratham G, Dennyson WG. Delayed traumatic intracerebral haemorrhage. J Neurol Neurosurg Psychiatry 1972;35:698-706.  Back to cited text no. 7
Diaconis JN, Rao KC. CT in head trauma: A review. J Comput Tomogr 1980;4:261-70.  Back to cited text no. 8
Mohindra S, Mukherjee KK, Gupta R, Chhabra R, Gupta SK, Khosla VK. Decompressive surgery for acute subdural haematoma leading to contralateral extradural haematoma: A report of two cases and review of literature. Br J Neurosurg 2005;19:490-4.  Back to cited text no. 9
Yoshino Y, Aoki N, Oikawa A, Ohno K. Acute epidural hematoma developing during twist-drill craniostomy: A complication of percutaneous subdural tapping for the treatment of chronic subdural hematoma. Surg Neurol 2000;53:601-4.  Back to cited text no. 10
Madhugiri VS, Arimappamagan A, Chandramouli BA. Traumatic epidural and subdural hematomas and extensive brain infarcts in a patient with pial arteriovenous malformation: Mechanisms underlying clinical and radiological findings. Asian J Neurosurg 2012;7:210-3.  Back to cited text no. 11
[PUBMED]  Medknow Journal  
Pickard JD, Bailey S, Sanderson H, Rees M, Garfield JS. Steps towards cost-benefit analysis of regional neurosurgical care. BMJ 1990;301:629-35.  Back to cited text no. 12
Agrawal A, Agrawal C, Kumar A, Adhikari S. Outcome of traumatic extradural haematoma managed surgically: Our experience. Niger J Orthop Trauma 2007;6:74-6.  Back to cited text no. 13
Agrawal A. Bilateral symmetrical parietal extradural hematoma. J Surg Tech Case Rep 2011;3:34-6.  Back to cited text no. 14
Kapsalaki EZ, Machinis TG, Robinson JS 3rd, Newman B, Grigorian AA, Fountas KN. Spontaneous resolution of acute cranial subdural hematomas. Clin Neurol Neurosurg 2007;109:287-91.  Back to cited text no. 15
Massaro F, Lanotte M, Faccani G, Triolo C. One hundred and twenty-seven cases of acute subdural haematoma operated on. Acta Neurochir (Wien) 1996;138:185-91.  Back to cited text no. 16


  [Figure 1], [Figure 2]

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