The patient was operated by me 10-September-1999 for ICH with AVM right parieto-occipital region and was doing well. The patient then came to the clinic from YAR 23-November-2014 with his relatives in wheelchair, telling that he suffered minor trauma to the head 2 months ago. he last 10 days got rapid deterioration of his condition with right sided weakness and gross memory deficit and difficult talking. He is in wheelchair for a week with Foley's catheter for one day. MRI of the brain performed in YAR 18-November-2014 bad quality and incomplete study. but showing huge chronic subdural hematoma left convexity and CT-scan the same day showing the same data. The patient is diabetic the last 5 years with controlled arterial hypertension before the first surgery.

On examination, the patient is in wheelchair with severe weak right upper and both lower limbs, with better power of the left distal muscles. The patient respond to verbal commands with difficulty and can count to 4 with difficulty. The relatives telling that he has severe memory impairment. Sensation was preserved all over. Babinski positive in the right side without clonus.

The patient was sent for MRI of the brain with contrast with MRA of the brain and carotids. The area of the previous surgery in the right parieto-occipital area is sclerotic without evidence of new vascular malformation. There is huge chronic subdural hematoma occupying the entire left hemisphere with major shift of the mid structures to the right and subfalcine herniation. There are mild to moderate stenosis of the right ICA just above the bifurcation from the CCA and the right MCA segments. 

Left fronto-parietal osteoplastic craniotomy with reflection of the flap to the left ear. The dura was opened in AP direction and the hematoma was evacuated and the cavity was washed meticulously to seek for active bleeding sites. There are several veins still bridging between the collapsed brain and dura under the dural incision. They were preserved. Ready vac drain was inserted to the most inferior point of the cavity and the dural was closed using nylon 4 zero. Routine closure of the wound.

Smooth postoperative recovery. The patient was sent to the ICU for 24 hour observation. Dramatic improvement of his neurological deficits.

The patient has profound neurological deficit due to major shift of the brain and distortion of the anatomical structures, which will suffer even without direct compression.