Symptomatic calcified subdural hematomas

Symptomatic calcified chronic subdural hematoma in an elderly patient: a case report

INTRODUCTION

Calcified chronic subdural hematoma is a rare and infrequent diagnosis made in clinical practice according to the literature. Calcification of chronic subdural hematoma is found more frequently in children and young adults than in the aged. The proposed mechanism of calcification may involve poor circulation and absorption in the subdural space together with intravascular thrombosis and prolonged existence of the hematoma in the subdural space.

CLINICAL PRESENTATION

An 84-year-old Ethiopian male patient presented with progressive right-sided body weakness of 8-month duration. The weakness started in the right lower extremity and progressively involved the upper extremity. Associated with the above complaint, he had had also a globalized headache of the same duration. Pre- and post-contrast brain computed tomography scans showed a right hemispheric extra-axial collection that crossed the suture line, with a maximum depth of 2.3 cm. Subsequently, craniotomy and hematoma evacuation were carried out and the patient was discharged improved.

CONCLUSION

The most common symptom of calcified chronic subdural hematoma is headache followed by lethargy, confusion, memory impairment weakness, and seizures. A diminished level of consciousness is relatively common and motor deficits are usually manifested as hemiparesis or gait disturbance. Most calcified chronic subdural hematomas can be diagnosed by computed tomography or magnetic resonance imaging and differentiated from the usual chronic subdural hematoma by imaging studies and gross pathology. Surgical treatment is advised in symptomatic patients when feasible, and often results in neurological improvement. Here we presented a patient with an uncommon calcified chronic subdural hematoma, which was successfully evacuated, resulting in a good recovery.

Bone Within Bone as a Calcified Subdural Hematoma

Calcified subdural hematoma (CSDH) is a very rare presentation but a known and reported entity in literature. Most of the case reports have been described in children and the elderly. Surgical treatment for CSDH is still considered controversial. We report here a case of calcified subdural hematoma in a middle-aged male that was successfully operated on. A 45-year-old male presented with complaints of right-sided weakness and seizures with a history of head trauma three years ago. Non-contrast computerized tomography (NCCT) head showed calcified subdural hematoma associated with mass effect and midline shift. A frontotemporoparietal craniotomy was done to remove the CSDH. Intra-operatively the brain was pulsating well. He was discharged on the 12th postoperative day and doing well on a follow-up visit.

Brain Herniation into the Subdural Space: Rare Iatrogenic Complication of Treatment of a Giant Calcified Subdural Hematoma

BACKGROUND

Chronic subdural hematoma associated with dural calcifications in previously pediatric shunted patients is a rare condition. The inner dural membrane opening can lead to progressive brain herniation into the subdural space due to brain reexpansion.

CASE DESCRIPTION

A 15-year-old boy, previously shunted at birth for congenital hydrocephalus, presented with a giant chronic right hemispheric subdural hematoma. After 2 surgical procedures in which the subdural calcified neomembrane was opened and a subdural shunt was implanted, he developed a cortical brain herniation into the subdural space, resulting in brain ischemia and upper limb weakness and vomiting. The final surgical treatment consisted of an extensive wide peeling of visceral calcified membrane mutually to programmable valve placement along the subduroperitoneal shunt, in order to create a positive gradient between the subdural space and the ventricles. The patient experienced a prompt clinical improvement.

CONCLUSIONS

This case illustrates a rare complication of the treatment of a chronic subdural hematoma caused by insufficient opening of the calcified inner mambrane of the hematoma and encouraged by gradient pressure between the ventricular and subdural compartments. To avoid this complication, it is preferable to not open a thick, calcified, unelastic inner membrane. However, in case of lack of clinical and radiologic improvement, it may become necessary to open it: a wide opening should be attempted, in order to prevent brain strangulation.

A case with a postoperative rapidly calcified subdural hematoma

We report a rare case of a rapidly calcified subdural hematoma (SDH) occurring 15 days after craniotomy in an adolescent. It suggests that calcification of a SDH may occur not only in the chronic stage but also in the subacute stage and may appear in subdural hematomas (SDHs) after craniotomy.

Calcified or Ossified Chronic Subdural Hematoma: A Systematic Review of 114 Cases Reported During Last Century with a Demonstrative Case Report

OBJECTIVE

Calcified or ossified chronic subdural hematoma (CSDH), characterized by slowly progressing neurologic symptoms, is a rarely seen entity that may remain asymptomatic for many years. Management of CSDH has improved dramatically in recent years as a result of advances in diagnostic tools, but there is still some controversy regarding the optimal treatment strategy.

METHODS

In this systematic review, PRISMA guidelines were followed to query existing online databases between January 1930 and December 2018. We found a total of 88 articles containing 114 cases of calcified or ossified CSDH, comprising 83 patients operated on and 31 not operated on.

RESULTS

In this study, there were 78 males and 29 females (7 with unreported gender) from 25 countries, ages ranging from 4 months to 86 years (mean, 33.7 years), with CSDH caused by head trauma in 33.3%, shunting for hydrocephalus in 27.2%, or after cranial surgery in 4.4%. The duration of symptoms ranged from acute onset to 20 years, with a mean of 24.1 months. Imaging techniques such as radiography, computed tomography, and magnetic resonance imaging were used, with pathologic confirmation of CSDH and complete recovery in 56.4% of patients.

CONCLUSIONS

Incidence of calcified or ossified CSDH is high in certain countries, including the United States, Japan, and Turkey, with a steady increase in recent years. The therapy of choice is surgery in these patients and it should be considered in the differential diagnosis at presentation because of its infrequency and variable clinical manifestation, after shunting in children or head trauma in adults.

Armored Brain Associated with Secondary Craniostenosis Development at 7-year following Ventriculoperitoneal Shunt Surgery during Infancy: Extremely Unusual Association and Review

Calcification is uncommon in chronic subdural hematoma and popularly known as calcified chronic subdural hematoma (CSSDH), and about hundred cases are reported in the form of isolated cases report. The calcified inner membrane of chronic subdural hematoma gets adherent to underlying cerebral cortex preventing re-expansion of the brain and producing mass effect. Calcification can develop in chronic subdural hematoma of traumatic origin or postmeningitic effusion or extremely rarely after shunt surgery. CCSDH is also known as armored brain or Matrioska head and those related to cerebrospinal fluid diversion ventriculoperitoneal (VP) shunt surgery, constitute one of the rare complications of shunt, and development is attributed to overdrainage of shunt. Authors report a unique case with bilateral calcified chronic subdural hematoma in an 8-year-old boy, who had VP shunt surgery for obstructive hydrocephalus at the age of 1 year of life, presented with feature of nonlocalized raised intracranial pressure; a diagnosis of suspected VP shunt malfunction was also considered; however, cranial computed tomography scan on current admission revealed the presence of bilateral calcified chronic subdural hematoma with secondary craniostenosis and managed successfully with burr-hole craniostomy and drainage of CCSDH. In a detailed PubMed and Medline search, authors could not get any publication regarding CSSDH associated with secondary craniostenosis developing following VP shunt surgery in infancy. The current case represents the first case in the Western literature developing secondary craniostenosis-associated CCSDH following shunt surgery in infancy, requiring surgical management. The clinical features, neuroimaging, and management of such rare case along with pertinent literature are reviewed briefly.

Armored brain in a young girl with a syndromal hydrocephalus

The authors present a case of a young girl affected by a syndromal hydrocephalus who developed a bilateral ossified chronic subdural hematoma with the typical radiological appearance of "the armored brain". Bilateral calcified chronic subdural hematoma is a rare complication of ventriculoperitoneal shunt. There is controversy in the treatment, but most published literature discourages a surgical intervention to remove the calcifications.

Bilateral Ossified Chronic Subdural Hematoma Presenting as Diabetes Insipidus-Case Report and Literature Review

Calcified chronic subdural hematomas are an occurrence rarely seen in neurosurgical clinical practice. And when they occur bilaterally, the radiologic image they present is fascinating, as is the clinical presentation, but their management may be challenging. They have been reported to present with a multitude of neurologic deficits but never with diabetes insipidus, which is described here. Due to the rarity of this pathology, the management protocol is not well defined, though there have been quite a few papers on this condition. This review article gathers information published over the years on this rare entity to suggest a treatment protocol.

Armoured brain of unknown etiology

Armoured brain is a rare condition where dense calcification occurs over the brain. It can result in mass effect and raised intracranial pressure. Most often, it happens due to trauma, subdural effusion, infection, or after VP shunt. There is controversy in its treatment. Most published literature does not support removing the calcification. We describe a rare case of idiopathic chronic calcified subdural hematoma with relatively short history which was successfully treated by microsurgical removal of calcification over the brain. This resulted in complete expansion of the brain with relief in symptoms.

Armoured brain due to chronic subdural collections masking underlying hydrocephalus

Calcified chronic subdural collection (armoured brain) is a known long-standing complication of shunt overdrainage. We report a young male who became symptomatic eleven years after a shunt surgery. Radiology showed bilateral calcified subdural collections. Drainage of these collections did not help, but shunt revision did. Patients with armoured brain syndrome who suddenly become symptomatic should possibly undergo shunt revision before the more extensive and morbid procedure of drilling the membranes.

Armored brain: A case report and review of the literature

Background:

Calcified chronic subdural hematomas occur infrequently. When the calcifications are extensive and bilateral, the condition is termed “armored brain”. We describe a case of “armored brain” incidentally discovered in an adult presenting with abdominal pain and mild headaches, long after initial placement of a ventriculo-peritoneal (VP) shunt.

Case Description:

A 38-year-old woman, treated at infancy with a VP shunt, presented with a 2-month history of abdominal pain associated with nausea and chills. She was neurologically intact on exam. An abdominal computed tomography (CT) scan demonstrated a rim-enhancing loculated fluid collection surrounding the patient's distal VP shunt catheter tip. As a part of her initial work-up, she received a head CT to evaluate the proximal VP shunt, which demonstrated large bilateral chronic subdural hematomas with heavily calcified walls. She was eventually taken to the operating room (OR) for replacement of the distal catheter. It was felt that her acute clinical presentation was unrelated to the bilateral, calcified subdural hematomas and thus the decision was made to manage them conservatively.

Conclusions:

This rare complication of chronic shunting for hydrocephalus is sometimes referred to as armored brain. Surgery for armored brain is infrequently indicated and beneficial in only small subgroup of patients, with management guided by clinical presentation. Our patient fully recovered after shunt revision alone.

Contralateral acute subdural hematoma occurring after removal of calcified chronic subdural hematoma

Supratentorial craniotomy for a nontraumatic lesion complicated by an acute subdural hematoma on the opposite side is rare. A 47-year-old woman presented with progressive headache and dizziness with no significant past history. Neuroimaging studies revealed a very large calcified chronic subdural hematoma over the entire right hemisphere with prominent mass effect. Despite a near total excision of the hematoma including the inner membranes by a large craniotomy with meticulous dissection, the brain parenchyma remained depressed. The dead space was therefore filled with saline and the operation was completed as usual. Repeat computed tomography scan for signs of left tentorial herniation demonstrated an acute contralateral subdural hematoma with severe shift of midline structures. We propose a prevention strategy for this event, which has not been previously described. We also discuss possible mechanisms involved in this unexpected complication.

White matter hyperintensities are related to physical disability and poor motor function

OBJECTIVE

To determine the impact of white matter hyperintensities (WMHs) on physical health and cognitive function in 60-64 year old individuals residing in the community.

METHODS

A subsample of 478 persons aged 60-64 from a larger community sample underwent brain magnetic resonance imaging (MRI) scans. WMHs on T2 weighted FLAIR (fluid attenuated inversion recovery) MRI scans were assessed using an automated procedure. Subjects were assessed for global cognitive function, episodic memory, working memory (digit span), information processing speed (Symbol Digit Modalities Test; SDMT), fine motor dexterity (Purdue Pegboard), and grip strength, and completed the Physical Component Summary of the Short Form Health Survey (SF-12). Regression analyses were used to examine the effect of WMHs on physical and cognitive function.

RESULTS

Deep and periventricular WMHs were present in all subjects, with women having slightly more lesions than men. WMHs were significantly associated with poorer reported physical health on the SF-12 scale, after adjusting for depression, cognitive function, and brain atrophy. WMHs were also related to lower scores on the Purdue Pegboard test, grip strength, choice reaction time, and SDMT, but not on tests of episodic memory, working memory, general intellectual function, and global cognitive function. On regression analyses, the Purdue Pegboard test and grip strength were related to physical disability.

CONCLUSION

WMHs are common, albeit mild, in middle adult life. They are associated with physical disability, possibly through reduced speed, fine motor coordination, and muscular strength. They are also related to slowed information processing speed but not other cognitive functions.

Intracranial hemorrhage and rebleeding in suspected victims of abusive head trauma: addressing the forensic controversies

Does an expanded subarachnoid space predispose to subdural bleeding? What does heterogeneity in the appearance of a subdural collection on CT or MRI imaging indicate? Spontaneous rebleeding? Minor re-injury? Major re-injury? In some specific cases, answers to these questions have important forensic implications. To conclude objectively that an infant's intracranial hemorrhage or rebleeding resulted from inflicted injury or re-injury requires an in-depth understanding of the pathogenesis of posttraumatic subdural and subarachnoid collections. The authors present two cases of indoor, accidental, pediatric, closed-head trauma that resulted in intracranial rebleeding. Both accidental cranial impacts occurred in medical settings and were independently witnessed by medical personnel. In addition, the authors summarize the relevant medical literature regarding pediatric intracranial bleeding and rebleeding.

An unusual post-traumatic occipitocervical pseudomeningocele: case report

BACKGROUND

A rare case of massive post-traumatic subcutaneous pseudomeningocele probably communicating with the cisterna magna, is reported.

CASE DESCRIPTION

An 8-year-old boy sustained a severe injury to the nape of the neck, after which he developed a huge local subcutaneous swelling containing cerebrospinal fluid (CSF). Communication of the subcutaneous CSF collection with the cisterna magna or any other site of dural fistula could not be identified. After a lumbo-peritoneal CSF shunt, the swelling resolved completely.

CONCLUSION

The clinical features of a rare case of symptomatic post-traumatic cerebrospinal fluid pseudomeningocele are elaborated.