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 28-year-old right-handed male with trauma signs on his head (a wound in his occipital region, nasal hemoliquorrhea, right-sided otohemoliquorrhea) was admitted to Yalta City Hospital after he felt down while riding a skateboard. On admission, he was Glasgow coma scale (GCS) 5 with left dilated pupil.\nCT scans showed intracerebral traumatic hematoma in the left frontal lobe, 6 mm midline shift, right temporal bone fracture and a small pneumocephalus in sellar region [].\nPerformed operation: left-sided hemicraniectomy through “trauma-flap” incision, evacuation of traumatic intracerebral hematoma in left frontal lobe. Intraoperatively an acute brain swelling occurred. Patient was transferred to ICU after the operation. One day after the operation, right-sided anisocoria occurred and a contralateral EDH with 10 mm of midline shifting was found at the control CT scans [].\nPatient underwent decompressive craniectomy in the right temporo-parietal region and evacuation of EDH about 100 cc in volume.\nOne day later there were no signs of residual hematoma on CT scans [].\nAt the fifth day after the operation, percutaneous tracheostomy was performed. Patient was comatose 19 days after admitting to the hospital. He underwent conservative treatment of brain edema. After that control CT scans were performed [].\nNext day patient became apallic and 7 days later akinetic mutism was found.\nAt the 32nd day in the hospital, he was transferred from the intensive care unit (ICU) into the neurosurgical department.\nOne month later patient was awake and spoke with single separated words.\nOn 76th day in the hospital the CT scans were performed with 1 mm collimation for the titanium mesh implants and stereolithographic models development [].\nAt his 2 month follow-up, he had neurological deficit of left-sided spastic hemiparesis, anosognosia, right-sided convergent strabismus.\nBilateral cranioplasty of two huge bone defects [Figures and ] with individually constructed titanium mesh was performed.\nPostoperative period was uneventful and in 15 days patient was sent to rehabilitation.\nCT scans in a month after the cranioplasty showed brain expansion to its original shape [].