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 [].
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.