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, 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.