Symptomatic Calcified Subdural Hematomas

Abstract

Two unique cases of chronic calcified subdural hematomas are reported in children as a long-term complication of a ventriculoperitoneal shunt. Both the patients had undergone shunt procedures in infancy for congenital hydrocephalus. In one patient, the cause of the hydrocephalus was aqueduct stenosis, while in the second patient, a lumbar meningomyelocele was associated with hydrocephalus. In both these patients, a ventriculoperitoneal shunt was done in infancy. In one of them, following the shunt surgery, a bilateral subdural collection was noticed which required burr hole evacuation. Both the patients remained asymptomatic for 9 years, when they presented to our center with acute raised intracranial pressure and contralateral hemiparesis. Both the patients had a relatively short history and had altered sensorium at admission. Surprisingly, in both the patients, the CT scan showed significant mass effect producing calcified subdural hematomas. The shunt systems were found to be working well at surgery. Craniotomy and excision of the calcified subdural hematomas was undertaken. Postoperatively, the patients showed satisfactory recovery, and at discharge the patients were doing well. At the follow-up at the outpatient clinic, the patients were asymptomatic.

‘Armoured Brain’

“…Aetiological theories include poor circulation, delayed haematoma absorption, stagnation and eventual calcification [2] . Others suggest abnormal metabolic factors may also play a role [3,4] .…”

“…Clinical presentations vary from the incidental finding to a multitude of acute and chronic symptoms including paresis, gait disturbances, chronic headaches, deteriorating vision, seizures, mental retardation, altered sensorium and acutely raised intracranial pressures [3][4][5][6] .…”

“…However, calcification of a chronic subdural haematoma after ventriculoperitoneal shunting is rare [2][3][4][5][6] . When extensive, the calcification resembles a shell encasing the brain, hence the term 'armoured brain' [5] .…”

Double-loculated Calcification Chronic Subdural Hematoma

“…[2][3][4]12,31 However, calcification is noticed in children secondary to overdrainage of the cerebrospinal fluid by shunting procedures, including ventriculoatrial or ventriculoperitoneal shunts. 3,10,11,13,21,24,27,29,30,36 Some authors also mentioned that initial meningitis may have contributed to the later development of subdural calcification, especially in children. 10,11 Fourth, clinical presentation of CCSDH varies widely, from asymptomatic to acute raised intracranial pressure.…”

Calcified Subdural Hematoma

“…We read with interest the article by Sharma et al [1] regarding symptomatic calcified subdural hematomas. They surgically removed the calcified subdural hematomas in their 2 hydrocephalic patients with ventriculoperitoneal shunts and obtained satisfying results.…”