IntroductionDecompressive surgery for acute subdural hematoma leading to contralateral extradural hematoma is an uncommon event with only few cases previously reported in the English medical literature.Case presentationThe present study describes the case of a 39-year-old White Brazilian man who had a motorcycle accident; he underwent decompressive craniectomy for the treatment of acute subdural hematoma and evolved contralateral extradural hematoma following surgery.ConclusionThe present case highlights the importance of close monitoring of the intracranial pressure of severe traumatic brain injury, even after decompressive procedures, because of the possible development of contralateral extradural hematoma.

RESUMOLesões cranianas penetrantes correspondem a uma causa incomum de traumatismo cranioencefalico diferentemente de ferimentos por projéteis de arma de fogo. A maioria dos casos relatados na literatura, embora notáveis pela gravidade, apresentam boa evolução pós-operatória. O objetivo do presente relato é descrever o caso de um homem brasileiro admitido com lesão craniana penetrante profunda por arpão e sem déficits neurológicos. Os autores discutem os principais mecanismos do trauma e realizam breve revisão científica da literatura sob os aspectos epidemiológicos e possíveis abordagens terapêuticas. O manejo neurocirúrgico precoce e apropriado, quando realizado por cirurgião experiente, pode contribuir consideravelmente no prognostico dos pacientes. Palavras Chave: trauma crânio-encefálico, lesões cranianas penetrantes; Arpão.ABSTRACT Penetrating brain injury due to low energy objects is an unusual cause of head trauma, unlike gunshot wounds. Most cases reported are noteworthy due to its large dimension and, sometimes, good functional outcome. The present report describes the case of a Brazilian man presenting with a deep penetrating brain injury by a harpoon and no neurologic deficits. We discuss the main mechanisms of trauma and make a brief review of the literature upon epidemiological aspects and possible therapeutic approach. The early and appropriate neurosurgical management, on experience hands, may improve considerably patient outcome.

Introduction Cerebral abscess is a suppurative infection of the cerebral parenchyma, which may occur due to contiguity, hematogenous dissemination of distant foci, secondary to open traumatic brain injuries, or be idiopathic. Clinical Case A 63-year-old male patient sought assistance due to a severe headache in the frontal region associated with chills and lack of appetite that started four days before. Clinical examination of the patient showed no significant changes. Imaging and laboratory tests on admission showed only nonspecific changes, such as leukocytes 18,540, platelets 517,000, and c-reactive protein 2,0. In such case, magnetic resonance imaging (MRI) of the skull was performed with contrast, showing the presence of expansive lesions compatible with multiple brain abscesses in the right parieto-occipital region. Discussion After excluding the main focus of hematogenous dissemination and in view of the identification of the agent Streptococcus intermedius by means of secretion culture collected through a surgical method, the hypothesis of abscess due to contiguous dental pyogenic foci was pointed out. Conclusion Dental evaluation showed multiple foci of infection with periodontitis and dental abscess, which were treated along with the use of antibiotics directed to the etiologic agent.

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