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 39-year-old White Brazilian man was admitted to our Emergency Department after a motorcycle accident on a highway. Although he was hemodynamically stable, a neurological assessment revealed a Glasgow Coma Scale (GCS) of six points and right eye mydriasis. No clotting dysfunction was detected by laboratory test. Computed tomography (CT) of his brain revealed right side ASDH, hemispheric edema and midline shift of 15.7mm with compression of his right lateral ventricle (Figure \n). He was immediately transferred to the Operating Room and a right decompressive craniectomy was performed. He was kept under sedation and his intracranial pressure (ICP) was continuously monitored in the intensive care unit. On the first postoperative day, he started to present elevated ICP refractory to hyperventilation and osmotic therapy. A new CT was then obtained and showed a large contralateral EDH (Figure \n) and frontal hemorrhage associated with catheter insertion. He was taken again to the Operating Room and surgical evacuation of the hematoma was performed. A brain CT following the second operation, revealed no residual EDH (Figure \n). He evolved hemodynamically unstable within the first 48 hours and no neurological improvement was observed after weaning sedation. He died on the ninth postoperative day.