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.
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.