A 30-year-old male, was admitted 1.5 hrs following trauma, with a GCS score of 7/15 and asymmetric but reacting pupils. A CT scan of the brain showed an acute SDH in the right fronto-temporo-parietal region with mass effect and midline shift []. There was also a thin EDH and a speck of extradural air in the contralateral temporal region, underlying an undisplaced fracture of the parietal bone, and diastasis of the squamosal suture [Figure and ]. He underwent emergency surgical evacuation of the SDH. A lax duroplasty, was performed, and the bone flap was not replaced, as the brain was tense. He remained under ventilator support, with the pupils equal and reacting to light. An hour later, his left pupil became dilated and nonreacting. A CT scan of the brain showed a large contralateral EDH and a thin SDH with midline shift, subfalcine, and uncal herniation []. The EDH showed mixed densities and “swirl sign” suggesting active hemorrhage. He underwent an emergency craniotomy, evacuation of the left EDH, and bipolar coagulation of the actively bleeding posterior branch of the middle meningeal artery (MMA). The dura was not opened, as the SDH was thin and the dura was lax after the evacuation of the EDH. Postoperatively, the pupils were again equal and reacting to light. A follow-up CT scan of the brain showed no residual EDH and a thin acute SDH []. His GOS-E was 7 (lower good recovery), at 6 months.
A 30-year-old male, presented after an hour following trauma, with a Glasgow Coma Scale (GCS) score of 6/15 and symmetric and reacting pupils. Computed tomography (CT) scan of the brain showed an acute SDH in the right fronto-temporo-parietal region with mass effect and midline shift []. There were linear fractures of the ipsilateral parietal, temporal, and occipital bones with pneumocephalus, in the vicinity, of the right transverse sinus []. He underwent emergency craniotomy and evacuation of the SDH. A lax duroplasty, was done and the bone flap not replaced, as the brain was tense. He remained neurologically stable on ventilator support, with symmetric and reacting pupils. A routine follow-up CT scan of the brain after 24 h showed an ipsilateral EDH straddling the transverse sinus, causing mass effect and herniation of the brain through the craniectomy defect []. He underwent emergency craniotomy and evacuation of the hematoma. His extended glasgow outcome score (GOS-E) was 8 (upper good recovery), at 6 months.