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.
We report a 19-year-old Caucasian male of Iranian Nationality with acute right-sided traumatic SDH (due to car accident) with presenting Glasgow Coma Scale score of 6/15 and CT evidence of severe brain swelling and associated midline shift and contralateral small fractural EDH in the temporoparietal region (). The patient was anisocoric (right sided mydriasis) at presentation. He underwent an emergent decompressive craniectomy and evacuation of the SDH. During surgery, the brain showed considerable swelling after hematoma evacuation and coagulation of the ruptured bridging vein causative of hematoma. Therefore, an augmentation duraplasty using free pericranial flap was performed. Regarding severe brain swelling during operation, a possible intracranial pathology amenable to surgery was suspected and immediate post-operative CT scan revealed expansion of the contralateral EDH. Due to mass effect of EDH, a second surgery was offered. The patient’s family declined second surgery for EDH evacuation. The patient was transferred to intensive care undergoing ICP monitoring. Despite all medical measures such as mannitol, high dose barbiturate therapy, and mild hypothermia, the patient's ICP remained high (about 25 mmHg). CPP was around 65 mmHg. Serial CT scans were performed the next days, showing right PCA territory infarct as well as expansion and spontaneous resolution of the EDH. The ICP remained relatively high (about 20 mmHg) in the following days. The patient was discharged 3 months after admission in persistent vegetative state.