A 20-year-old man presented to our Hospital with severe brain trauma, hit by a car while he was riding a bike. On the arrival at the emergency room (ER) his Glasgow Coma Scale (GCS) was 4 (eyes 1; verbal 1 and motor 2) with fixed midriatic pupils and submitted to mechanical ventilation. A CT scan was performed and revealed a subdural hematoma, midline shift greater than 5mm and a swelling, Marshall V (surgically evacuated). The patient was submitted to a decompressive craniectomy and hematoma evacuation two hours after the accident and sent to ICU with ICP monitoring. About 48 hours after surgery a new CT scan was performed and revealed a good outcome with regression of the edema, no midline shift and then we suspended the sedation and 7 days after the trauma the patient woke up without neurological deficits. Some authors did not see benefits in early surgery although the average time of surgical approach was 5 hours after the accident and in many cases the worse patients that underwent to early surgery had a poor outcome. We did not find a specific paper describing the outcome in patients with a very poor GCS ( less than 5 ) and fixed pupils, although the pupils abnormalities remains a critical feature for surgical indication. We believe that even in patient with severe brain trauma, poor GCS and non-reactive pupils, early surgery especially if it is performed before 4 hours can probable improves the outcome, considering other clinical features such as blood pressure and oxygen saturation