A 51-year-old female was admitted with a head injury after a pedestrian accident. Upon admission, one hour after the accident, she had a GCS of 14. Brain CT revealed an EDH in the right temporoparietal area, SDH in the left frontal area (), and skull fracture in the right temporal and left frontal bone. Emergency right craniotomy was performed and the EDH was evacuated. Softened dura matter was found after performing craniectomy. Intraoperative TCS applied to the craniectomy site revealed volume expansion of the EDH in the left frontal area (). The bone flap was repositioned. Her vital signs were stable, and she was transported to the CT room. Brain CT confirmed the presence of a de novo EDH in the left frontal area. As a result, a second operation was performed on the left side. Her postoperative GCS score was 14, and the patient was discharged on hospital day 20 with no definite neurological deficit.
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.