A 19-year-old Chinese man involved in a motor vehicle accident was admitted to the emergency department presenting with a Glasgow Coma Scale (GCS) of 3 and right eye mydriasis. A computed tomography (CT) scan of his brain revealed right-side ASDH and a midline shift of 14.5 mm with severe brain swelling (Figs. and ). He was hemodynamically stable, with no clotting dysfunction according laboratory tests. He was subsequently transferred to the operating room and underwent a right decompressive craniectomy. The ASDH was caused by a ruptured lateral fissure vein. The brain exhibited slowly progressing swelling after the hematoma and inactivated brain tissue were evacuated. Consequently, immediate augmentation duraplasty using artificial dura mater was performed. On examination, the patient exhibited bilateral mydriasis. Given the slowly progressing brain swelling, this was possibly due to delayed contralateral ASDH or EDH. A CT scan of the brain was performed immediately thereafter, which revealed the emergence of contralateral DEH (Fig. ). Owing to a mass effect from the DEH and severe brain swelling, the patient was immediately taken to the operating room to undergo a left hematoma evacuation and decompressive craniectomy. During surgery, it was determined that the DEH was caused by the rupture of the middle meningeal artery branch, with temporal and occipital bone fractures (Fig. ). Following surgery, the patient was transferred to the neurological intensive care unit, where the left and right pupil sizes were measured to be 2.0 mm and 5.0 mm, respectively.\nOn postoperative day 1, approximately 5 h after the second surgery, the primary nurse found that the size of the patient’s left pupil gradually increased from 2.0 mm to 3.5 mm. An immediate brain CT scan revealed evidence of left-side DEH of the posterior cranial fossa (Fig. ). Owing to mass effect of the DEH, a third surgery was offered. He underwent left posterior cranial fossa hematoma evacuation and decompressive craniectomy. During the third surgery, it was determined that the DEH was caused by a ruptured transverse sinus. A brain CT following the third surgery was performed (Fig. ). The patient recovered to a GCS of 7 within 40 days after surgery, and was transferred to the rehabilitation hospital. He was ultimately discharged from the rehabilitation hospital with a Glasgow Outcome Score of 4. He underwent cranioplasty 1 year later and has since recovered well.
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.