Armored brain: A case report and review of the literature

Surgical Management of the Armored Brain: Case Report of the Treatment of a Chronic Calcified Subdural Hematoma

Calcified chronic subdural hematomas (CCSDHs) are rare entities, whose yearly incidence ranges from 1.72 to 20.6 per every 100 thousand persons. Several different approaches to their management are reported in the literature, ranging from conservative treatment to craniotomy with full removal of the neomembranes. Currently, there are no guidelines or consensus that establish the best technique. We herein report a case of symptomatic CCSDH initially drained through a burr-hole craniotomy, with no resolution of the symptoms. Later, our patient underwent a craniotomy and partial membranectomy, which resulted in full symptomatic recovery.

An early presentation of a large calcified chronic subdural hematoma presenting as an inner eggshell in an elderly patient: A case report

INTRODUCTION

Calcified chronic subdural hematoma which is usually found in children and takes several months for calcification to be seen on imaging is presented in an elderly patient in which the calcification could be visible early after trauma.

PRESENTATION OF CASE

An elderly man, 83, living with caregiver, was brought to our hospital due to dysarthria and suffocation for 2 days. Three months ago, he experienced his head injury from a fall. Four days ago, he developed progressive left hemiparesis. Because of clinically progressive deterioration and computed tomography scan revealing acute epidural hematoma, the patient was transferred to operating room. Gross findings and pathologic reports unfolded that the lesion was consistent with calcified chronic subdural hematoma. Despite a successful operation, the patient cannot survive.

DISCUSSION

In addition to the presentation in an elderly patient, there was scarcely any paper reporting an early presentation of calcium deposition. Nevertheless, according to the lack of previous data recorded for his earlier performance, deviation on walking or sitting, before the accident, we cannot actually know whether there has been calcium deposition in his brain before or not.

CONCLUSION

Calcified chronic subdural hematoma could present in elderly group of patient and early presentation of calcium deposition following trauma is possible. However, surgery in this group of patient entails a risk of fatality, despite the successful operation.

Progressively enlarging childhood chronic subdural hematoma surgically treated 26 years after diagnosis

Pediatric chronic subdural hematoma (CSDH) is a relatively common disorder. Treatment often requires burr hole drainage or subduroperitoneal shunt placement; some patients are managed conservatively. However, the long-term outcome of untreated pediatric CSDH is unknown. The authors report a case of a huge, progressively enlarging subdural granuloma that was surgically treated 26 years after the initial diagnosis of CSDH. This 30-year-old male patient presented with worsening intermittent atonic seizure-like movements, which had been noted since he was 4 years old. At that time, the patient was diagnosed with CSDH at an outside hospital, but an operation was refused by the parents. Magnetic resonance imaging (MRI) performed at 23 years of age showed a huge subdural mass on the right frontoparietal region and a smaller mass on the left side with a significant midline shift. Upon presentation at the age of 30, MRI revealed worsening of the right subdural mass and midline shift. Subsequently, the patient underwent craniotomy and subtotal removal of the mass and capsule. The volume of the content was approximately 430 cc. Untreated pediatric CSDH can grow progressively, even over several decades. Patients with CSDH, especially those managed conservatively, should be closely monitored for worsening symptoms over a long-term follow-up period.

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 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.