A 30-year-old male, presented after an hour following trauma, with a Glasgow Coma Scale (GCS) score of 6/15 and symmetric and reacting pupils. Computed tomography (CT) scan of the brain showed an acute SDH in the right fronto-temporo-parietal region with mass effect and midline shift []. There were linear fractures of the ipsilateral parietal, temporal, and occipital bones with pneumocephalus, in the vicinity, of the right transverse sinus []. He underwent emergency craniotomy and evacuation of the SDH. A lax duroplasty, was done and the bone flap not replaced, as the brain was tense. He remained neurologically stable on ventilator support, with symmetric and reacting pupils. A routine follow-up CT scan of the brain after 24 h showed an ipsilateral EDH straddling the transverse sinus, causing mass effect and herniation of the brain through the craniectomy defect []. He underwent emergency craniotomy and evacuation of the hematoma. His extended glasgow outcome score (GOS-E) was 8 (upper good recovery), at 6 months.
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.