A giant bilateral calcified chronic subdural hematoma

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.

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.

A Tortuous Process of Surgical Treatment for a Large Calcified Chronic Subdural Hematoma

BACKGROUND

Calcified chronic subdural hematoma (CCSDH) is a rare disease for which no standard approach to treatment has been established. Reports covering both burr hole trepanation and craniotomy for CCSDH are rare. Furthermore, infection of CCSDH after the burr hole trepanation has not been reported in the literature.

CASE DESCRIPTION

A 61-year-old man presented with left frontotemporoparietal CCSDH demonstrated on computed tomography (CT) scan. The patient underwent 2 separate burr hole trepanations with intraoperative irrigation and postoperative drainage. These procedures led to infection of the CCSDH. The patient eventually underwent an open craniotomy to provide complete removal of the hematoma.

CONCLUSIONS

Owing to the complex contents of a CCSDH, burr hole trepanation cannot adequately drain the hematoma or relieve the mass effect. Craniotomy is a much more reliable approach for achieving complete resection of a CCSDH.

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.

Traumatic Pseudoaneurysm Related to Calcified Nodules of Cerebral Convexity Dura Mater in an American College Football Player

Repeated concussion is common among football players; however, these minor blunt head trauma rarely result in serious complications. We report a case of a young college football player who presented acute subdural hematoma, cerebral edema, and seizure due to pseudoaneurysm rupture. The pseudoaneurysm, located at the cortical branch of the middle cerebral artery, was speculated to be formed by dural calcification and adhesion with the underlying brain, possibly due to repeated concussions. Following successful excision of the pseudoaneurysm and control of brain swelling, the patient recovered without sequelae and was discharged after a short while.

A massive calcification and ossification of the transverse sinus and the neighbouring dura mimicking meningioma

BACKGROUND

Although small calcifications of the dura and the transverse sinus occur frequently, large, single intracranial calcifications originating from the transverse sinus and the neighbouring dura are rare.

CASE PRESENTATION

A 47-year-old man was admitted to the hospital for a right occipital headache that had persisted for two weeks. There was no neurological deficit. Normal skull X-ray and computed tomography (CT) scans revealed an irregular, calcified, intracranial lesion of approximately 4.4 × 4.0 × 2.5 cm in volume in the right occipital region. Via surgery, a bone-hard, poorly vascularised, pink mass originating from the right transverse sinus and the convex dura of the right cerebellar hemisphere, as well as the cerebellar tentorium, was completely removed. Pathological examination yielded a diagnosis of fibrous connective tissue with hyaline degeneration, calcification and ossification with no indication of neoplasia or inflammation.

CONCLUSIONS

We report a rare case of massive calcification and ossification of the transverse sinus and the neighbouring dura mimicking meningioma. Degenerative calcification and ossification may serve as a rare differential diagnosis of diseases, such as meningiomas, in the transverse sinus and the neighbouring dura.

Multiple tenting techniques improve dead space obliteration in the surgical treatment for patients with giant calcified chronic subdural hematoma

BACKGROUND

Calcified chronic subdural hematoma (CCSDH), or "armored brain," is a rare disease entity. The optimal surgical procedure for CCSDH has not been established because it is hard to obtain brain re-expansion after surgery. In particular, a large CCSDH is difficult to completely extirpate, and the residual rigid inner and outer membranes facilitates dead space retention and hematoma recurrence.

METHODS

We introduce the use a multiple suturing technique to tent the residual outer and inner membranes onto the dura matter so as to obliterate dead space after surgical treatment for CCSDH. Neuroimaging and surgical reports with illustrative images from two cases are shown.

RESULTS

Two patients were admitted to our intensive care unit more than 10 years apart from their ventriculoperitoneal (V-P) shunt placements. The first patient presented with clinical signs of increased intracranial pressure. The second patient had a large CCSDH as a concomitant finding with ruptured aneurysmal subarachnoid hemorrhage. Computerized cranial tomography demonstrated large hematoma cavities with thick calcified inner membranes. After neurosurgical intervention by craniotomy and optimal resection of calcified membranes and muddy blood clot, we tented the residual calcified inner and outer membranes onto the dura matter by multiple sutures to reduce dead space accumulation. Postoperatively, the two patients had improved clinical symptoms along with much reduced hematoma cavity in imaging examinations.

CONCLUSIONS

We reported an alternative technique using multiple tenting procedures to improve dead space obliteration after surgical treatment for patients with a large CCSDH presenting as a late complication after V-P shunting.