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Table of Contents    
LETTER TO EDITOR
Year : 2015  |  Volume : 63  |  Issue : 3  |  Page : 457-458

Post ventriculo-peritoneal shunt chronic calcified hematoma or an abscess: A dilemma


Department of Neurosurgery, Grant Medical College and Sir Jamsetjee Jeejebhoy Group of Hospitals, Byculla East, Mumbai, Maharashtra, India

Date of Web Publication5-Jun-2015

Correspondence Address:
Hrushikesh Umakant Kharosekar
Department of Neurosurgery, Grant Medical College and Sir Jamsetjee Jeejebhoy Group of Hospitals, Byculla East, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.158272

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How to cite this article:
Naik HR, Kharosekar HU, Jasmit S, Velho V. Post ventriculo-peritoneal shunt chronic calcified hematoma or an abscess: A dilemma. Neurol India 2015;63:457-8

How to cite this URL:
Naik HR, Kharosekar HU, Jasmit S, Velho V. Post ventriculo-peritoneal shunt chronic calcified hematoma or an abscess: A dilemma. Neurol India [serial online] 2015 [cited 2019 Nov 22];63:457-8. Available from: http://www.neurologyindia.com/text.asp?2015/63/3/457/158272


Sir,

Calcified chronic hematoma is a rare but known complication that may occur after a ventriculo-peritoneal (V-P) shunt procedure. Very few cases of post V-P shunt calcified subdural hematomas have been reported in literature. [1],[2] The occurrence of an abscess after a V-P shunt is a known entity in post-traumatic hydrocephalus. Although surgical treatment is well defined for a chronic subdural hematoma, the protocol of management of a calcified chronic subdural hematoma causing mass effect is still nebulous.

We report an eight-year old male child who suffered a road traffic accident. He sustained a head injury and presented in an unconscious state at a tertiary care center in January 2012. A left decompressive craniectomy with flap reconstruction was performed for left fronto-temporal contusions with avulsion injury of the scalp. He improved in sensorium and was subsequently discharged without any deficits. One-and-a half year later, in June 2013, his parents noticed a gradual decline in his cognitive abilitives associated with a right-sided weakness in limbs. His repeat computed tomographic (CT) scan of the brain was showing hydrocephalus and therefore, he underwent a V-P shunt procedure. There was no significant improvement 3 months after the V-P shunt so a magnetic resonance imaging (MRI) of the brain was performed in October 2013. The MRI was suggestive of a hyperintense circumscribed lesion in the left fronto- parietal region, which on CT scan of the brain showed an isodense lesion with a hyperdense circular border [Figure 1]. The differential diagnosis considered included an abscess and a calcified hematoma. The patient was investigated for the presence of an infective etiology. The two dimensional echocardiography, a complete blood count and blood culture were found to be normal. The ultrasound abdomen and CT thorax were also normal. As the patient's cognitive decline was not related to his existing lesion and there was no mass effect, an ultrasound (USG)-guided aspiration of the fluid within the intracranial lesion was performed. On USG, the lesion showed a calcified rim and the fluid aspirated was altered blood [Figure 2]. The post-procedural scan showed complete resolution of the hematoma. As an abscess was ruled out and the repeat scan was showing hydrocephalus with a misplaced shunt, the V-P shunt was revised. The post-procedural scan after 5 days showed a decrease in the size of the ventricles [Figure 3]. There was no change in the patient's condition at discharge.
Figure 1: Preoperative plain cranial CT scan showing the calcified haematoma

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Figure 2: Intraoperative ultrasound showing the calcified rim

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Figure 3: Post-aspiration plain CT scan showing the resolution of the hematoma with decrease in hydrocephalus

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A chronic calcified hematoma may cause seizures, headache or hemiparesis but occasionally is found incidentally without any symptoms. It is a rare entity and occurs more frequently in children and young adults than in the aged. The rapidity of development of calcification within the capsule of a chronic subdural hematoma is unclear. After hemorrhage, calcification usually takes 6 months to many years to develop. The proposed predisposing factors for the development of calcification include a poor circulation and absorption within the lesion together with an ongoing intravascular thrombosis, stagnant blood due to insufficient arterial supply and inadequate venous return, and the presence of a thick connective tissue membrane. A surgical procedure for treating a calcified chronic subdural hematoma should be considered for the patients having an acute or progressive neurological deficit. [1]

Chronic calcified hematomas are rare entities that are usually well-tolerated due to their indolent nature even though the radiologic findings may be quite impressive. In our patient, the history of trauma, the shunt procedure as well as the radiological picture gave an erroneous impression of an abscess. An ultrasound guided aspiration through the preexisting hemi-craniectomy defect, however, established the presence of a calcified hematoma.

 
  References Top

1.
Pappamikail L, Rato R, Novais G, Bernardo E. Chronic calcified subdural hematoma: Case report and review of the literature. Surg Neurol Int 2013;4:21.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Djoubairou B O, Gazzaz M, Dao I, Mostarchid BE. Chronic calcified extradural and subdural hematoma following a ventriculoperitoneal shunt placement. Neurol India 2015;63:282-3.  Back to cited text no. 2
[PUBMED]  Medknow Journal  


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