Computed tomography of the "armored brain"

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.

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.

Chronic calcified subdural hematoma - case report of a rare diagnosis

INTRODUCTION

Chronic calcified/ossified subdural hematoma is a rare diagnosis. The incidence of chronic calcified subdural hematoma is 0.3-2.7% of all chronic subdural hematomas. Surgical treatment is indicated in most cases, but there is still some controversy.

MATERIALS AND METHODS

We present a case report of 81-year-old woman with calcified chronic subdural hematoma. Patient underwent an osteoplastic left craniotomy, evacuation of chronic subdural mass with careful dissection andsuccessful removal of inner and outer membrane. Postoperative CT scan showed removal of subdural hematoma, decrease of left shift of median line and good brain re-expansion. Postoperative period was without any serious complications.

RESULTS

Subdural hematoma was successfully removed, resulting in a good recovery with complete resolution of patients symptoms. From our experience, we highly recommend surgical treatment in cases of chronic symptomatic calcified subdural hematomas.

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.

Intracranial calcification caused by a brain abscess : a rare cause of intracranial calcification

Intracranial calcifications are relatively common computed tomographic findings in the field of neurosurgery, and cysticercosis, tuberculosis, HIV, and cryptococcus are acquired intracranial infections typically associated with calcifications. However, intracranial calcification caused by a bacterial brain abscess is rare. Here, we present a rare case of intracranial calcification caused by a bacterial brain abscess, from which staphylococcus hominis was isolated. To the best of our knowledge, no previous report has been published on intracranial calcification caused by bacterial brain abscess after decompressive craniectomy for traumatic brain injury. In this article, the pathophysiological mechanism of this uncommon entity is discussed and relevant literature reviewed.

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.

A giant bilateral calcified chronic subdural hematoma

BACKGROUND

A calcified chronic subdural hematoma is a rare disease and its neuroradiological presentation is variable. The degree of calcification extends from thin calcified inner membranes to dense calcification and even ossification of the hematoma. Previous reports described a maximum of two hematoma cavities with calcified inner hematoma membranes.

METHODS

Neuroimaging report with illustrative computerized tomography images.

RESULTS

A patient with a bilateral symptomatic calcified chronic subdural hematoma, or so-called "armoured brain", was admitted to our intensive care unit with clinical signs of increased intracranial pressure. Computerized cranial tomography demonstrated multiple bilaterally located hematoma cavities with thin calcified inner membranes. After neurosurgical intervention by bilateral burr hole trepanation, clinical symptoms improved.

CONCLUSIONS

Our case of a calcified chronic subdural hematoma presents with an uncommon imaging pattern with more than four hematoma cavities bounded by predominantly convex- and concave-configured thin calcified inner membranes.

Bilateral organized chronic subdural haematomas: high field magnetic resonance images and histological considerations

The authors describe a 66-year-old man with progressive gait disturbance caused by bilateral organized chronic subdural haematomas. The characteristics of these lesions on magnetic resonance (MR) images have not yet been clarified. The organized haematoma in our patient exhibited slight hypo-intensity on T 1-weighted MR images and marked hypo-intensity on T 2-weighted MR images obtained at 1.5T. Preoperative MR imaging may give us useful information about surgical strategy in the case of chronic subdural haematoma with an unusual appearance on computed tomographic (CT) scans.

High-field magnetic resonance image of a huge calcified chronic subdural haematoma, so-called "armoured brain"

Calcification of chronic subdural haematoma is called "armoured brain" when it covers most of the cortical surface. We report high-field magnetic resonance images of the armoured brain, and discuss the relationship between operative findings, computer assisted tomographic (CT) findings and the change in relaxation time on magnetic resonance images. In our case, low, iso, and high density layers were detected on computer assisted tomography. The change in relaxation time of a liquefied haematoma showed good agreement with chronological change in intracerebral haematoma, and the material was easily detected on magnetic resonance images. But with a grainy and mud-like haematoma, the change in relaxation time did not coincide with the state of the intracerebral haematoma. It is generally said that in the detection of a calcified mass, computer assisted tomography is superior to magnetic resonance images and this was also true in the present case. While there are a few reports on computer assisted tomographic findings for the armoured brain, this is probably the first report on high-field (1.5T) magnetic resonance imaging of the armoured brain.

Age-dependent changes of cerebral ventricular size. Part I: Review of intracranial fluid collections

The age distributions of communicating hydrocephalus (CH), pseudotumour cerebri (PC) slit-ventricle syndrome (SVS), and chronic subdural haematomas (CSH) were reviewed in the medical literature. An age-related incidence was found: CH and CSH predominated in neonates less than 2 years and adults older than 55 years, while PC and SVS occurred mainly in older children and young adults. The latter two patient groups seem to show a greater resistance to ventricular dilatation in the presence of decreased CSF absorption. This may be related to larger volume and state of maturity of the cerebrum. On the other hand, neonates and the elderly more readily develop enlarged ventricles, in association with impairment of CSF absorption, or subdural fluid collections. Factors including status of cranial sutures, cerebral atrophy, cerebral water content, degree of cerebral myelination, and glial cell composition, may contribute to the age-related incidence of the four disorders investigated. Similarly, the development of ventriculomegaly may depend upon cerebral elastic properties besides the pri mary disturbance of CSF dynamics. The authors postulate that the size of cerebral ventricles in disorders of the cerebrospinal fluid (CSF) absorption is related to the elastic properties and volume of the brain. Furthermore, cerebral volume and elastic properties may also contribute to the age distribution of chronic subdural haematomas (CSH).

Nontumoral aqueductal stenosis in children affected by von Recklinghausen's disease

The authors report three cases of primary nontumoral aqueductal stenosis associated with von Recklinghausen's disease in children. Moreover, 16 similar cases collected from the literature are presented. The clinical features are evaluated in light of data from the literature. Among all 19 cases, the median age was 19 years (range 6-46 years), and nine patients were under the age of 13 years. Our own patients underwent ventriculoatrial shunt procedures, followed by clinical recovery (follow-up 2-5 years). In one patient, computed tomography scanning performed 20 months after the operation showed a chronic calcified subdural hematoma in the right frontoparietal area. In conclusion, it is felt that, among all the pathological events usually described in patients affected by neurofibromatosis, primary aqueductal stenosis seems to be part of the natural history of this neurological syndrome.