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LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 5  |  Page : 548-550

Armored brain-Massive bilateral calcified chronic subdural hematoma in a patient with ventriculoperotoneal shunt


Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi-110 029, India

Date of Submission12-Aug-2013
Date of Decision25-Aug-2013
Date of Acceptance25-Aug-2013
Date of Web Publication22-Nov-2013

Correspondence Address:
Pankaj Kumar Singh
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi-110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.121950

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How to cite this article:
Garg K, Singh PK, Singla R, Chandra P S, Singh M, Satyarthhe GD, Gurjar HK, Sharma BS. Armored brain-Massive bilateral calcified chronic subdural hematoma in a patient with ventriculoperotoneal shunt. Neurol India 2013;61:548-50

How to cite this URL:
Garg K, Singh PK, Singla R, Chandra P S, Singh M, Satyarthhe GD, Gurjar HK, Sharma BS. Armored brain-Massive bilateral calcified chronic subdural hematoma in a patient with ventriculoperotoneal shunt. Neurol India [serial online] 2013 [cited 2019 May 25];61:548-50. Available from: http://www.neurologyindia.com/text.asp?2013/61/5/548/121950


Sir,

Calcification in chronic subdural hematoma (CSDH) is uncommon and occurs in about 0.3%-2.7% cases. [1] This complication has rarely been reported in patients with CSDH following ventriculoperitoneal shunt for hydrocephalus.

A 24-year-old male presented with progressive bilateral vision loss and polyuria since 2001. Investigation at other facility showed visual acuity of 6/9 in both eyes and imaging revealed communicating hydrocephalous for which he underwent right parietal ventriculoperitoneal shunt in 2004. This was followed by improvement in both vision and polyuria. He was doing well till 2008, when he again started having polyuria and painless progressive visual diminution. He presented to us in 2012 with these complaints, and the visual acuity was perception of hand movements close to face with bilateral secondary optic atrophy. Noncontrast brain computed tomography (CT) revealed bilateral frontoparietal calcified chronic subdural hematoma and right parietal shunt in situ [Figure 1] and [Figure 2].
Figure 1: (a, b) Non contrast CT head done in 2007 revealing left frontotemporal calcified subdural hematoma with mass effect with minimal collection on right side, (c, d) Non contrast CT head done in 2012 revealing bilateral frontotemporal calcified subdural hematoma (left > right) with right parietal shunt in situ

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Figure 2: (a) T1WI axial section showing hyperintense left frontotemporal extraaxial collection and hypointense right frontal collection, (b) T2WI axial section showing left frontotemporal extraaxial hypointense collection compressing the brain parenchyma, and (c) T2WI coronal section showing bilateral extraaxial hypointense collection compressing the brain parenchyma (left > right)

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Calcified CSDH is also described as armored brain or Matrioska head. [1] Taha [2] could find only 18 such cases in the literature till 2012. The exact mechanism of calcifications is still an enigma. Microscopic calcium deposits within the membranes of the hematoma may proceed to extensive calcification and even ossifications in some cases. An underlying metabolic abnormality and poor circulation with delayed resorption of the hematoma fluid are other putative factors.

These patients may be asymptomatic and when symptomatic present with signs of elevated intracranial pressure, seizures, and mental retardation. Symptoms may develop many years after shunt surgery. [3] CT or magnetic resonance imaging confirms diagnosis and can also differentiate it from other calcified extraaxial lesions like calcified epidural hematoma, meningioma, and malignant tumors. [4] The management of calcified chronic subdural hematoma is a matter of controversy and it is recommended that surgical intervention should be limited to patients who have progressive neurological deficits or evidence of increased intracranial pressure.

 
  References Top

1.Sharma RR, Mahapatra A, Pawar SJ, Sousa J, Athale SD. Symptomatic calcified subdural hematomas. Pediatr Neurosurg 1999;31:150-4.  Back to cited text no. 1
[PUBMED]    
2.Taha MM. Armored brain in patients with hydrocephalus after shunt surgery: Review of the literatures. Turk Neurosurg 2012;22:407-10.  Back to cited text no. 2
[PUBMED]    
3.Amr R, Maraqa L, Choudry Q. 'Armoured brain'. A case report of calcified chronic subdural hematoma. Pediatr Neurosurg 2008;44:88-9.  Back to cited text no. 3
[PUBMED]    
4.Kaspera W, Bierzynska-Macyszyn G, Majchrzak H. Chronic calcified subdural empyema occurring 46 years after surgery. Neuropathology 2005;25:99-102.  Back to cited text no. 4
    


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[Pubmed] | [DOI]



 

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