A 22-year-old male skid and fell from a motorbike. He was unconscious since the time of the incident and had multiple episodes of vomiting with ear and nasal bleed. There was no history of seizures. On examination, he was afebrile, pulse rate was 87/min, and blood pressure was 120/70 mm/Hg. His Glasgow coma score was E2M2V1. The right pupil was 2 mm reacting to light, and the left pupil was 4 mm sluggishly reacting (Fig. 1a). The patient was spontaneously decerebrating with paucity of movement on the left side. In view of poor GCS, he was intubated and electively ventilated. A CT scan of the brain showed thick right parieto-occipital extradural hematoma with mass effect, underlying contusion, bifrontal patchy contusions (left > right), linear fracture of the right occipital bone with significant cerebral edema, mass effect, distortion, and displacement of the brain stem (Fig. 1b and c). His blood investigations including coagulation profile were within normal range. The patient underwent emergency right parieto-occipital craniotomy and evacuation of extradural hematoma. The patient was electively ventilated. Following the evacuation of the hematoma, the pupillary asymmetry resolved in immediate post-operative period. The patient underwent an early tracheostomy, gradually weaned off from the ventilator, and could be shifted to ward. He received regular chest and limb physiotherapy. He could be weaned off from tracheostomy and improved to GCS E4V5M6.