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38 Published by DiscoverSys | IJN 2019; 2(2): 38-41 | doi: 10.15562/ijn.v2i2.35
CASE REPORT
ABSTRACT
Open access: https://ina-jns.org/
A successfully excised in toto of loculated calcied
chronic subdural hematoma: A case report
Satya Bhusan Senapati1,4*, Yoko Kato2, Lavlesh Rathore1,3
Background: Calcied chronic subdural haematoma (CCSDH)
is a rare complication of a relatively more common condition of
Chronic Subdural Haematoma (CSDH). There is conicting opinion
regarding management of such type of disease.
Aim: Surgical procedure for this type of lesion has not been
established due to the limited expansion of the brain after surgery.
This is probably related to the presence of a thick calcied inner
membrane, which is frequently adherent to the cortical surface of
the parenchyma, limiting the dissection from the brain.
Case report: We report a case of CCSDH which was successfully
excised in toto with good neurological outcome and post-operative
Computed Tomography (CT) scan documented brain expansion.
Conclusion: From our experience with present case we conclude
that such well loculated calcied thick CSDH can be safely excised in
toto if following points are taken care. First, craniotomy is properly
planned to expose a healthy dural margin of 1 cm beyond calcied
lesion all around. Second, non-calcied vascular membrane of
CSDH attached to margin of CCSDH are cauterized before incised.
Third, care taken during dissection of CCSDH from parenchymal
surface preserving the arachnoid. Further study regarding the
pathogenesis of CCSDH may help us in preventing the development
of this unique entity.
Keywords: armoured brain, calcied chronic subdural haematoma,
chronic subdural hematoma
Keywords: armoured brain, calcied chronic subdural haematoma, chronic subdural hematoma
Cite This Article: Senapati, S.B., Kato. Y., Rathore, L. 2019. A successfully excised in toto of loculated calcied chronic subdural hematoma:
A case report. Indonesian Journal of Neurosurgery 2(2): 38-41. DOI:10.15562/ijn.v2i2.35
1Fellow at Fujita Health University,
Banbuntane Hotokukai Hospital,
Japan
2Department of Neurosurgery,
Fujita Health University,
Banbuntane Hotokukai Hospital,
Japan
3Shree Balaji Institute of Medical
Sciences, Raipur, India
4Sikkim Manipal Institute of
Medical Sciences, Gangtok, India
*Corresponding to:
Satya Bhusan Senapati; CRH,
SMIMS, 5th Mile, Tadong, Gangtok,
Sikkim, India;
satya.bhusan.senapati@gmail.
com
Indonesian Journal of Neurosurgery (IJN) 2019, Volume 2, Number 2: 38-41
P-ISSN.2089-1180, E-ISSN.2302-2914
Received: 2018-11-21
Accepted: 2019-04-01
Published: 2019-08-01
38
INTRODUCTION
Calcied chronic subdural haematoma [CCSDH]
is an infrequent complication of the more common
condition of chronic subdural haematoma.1,2 It was
rst described in 1884 as a postmortem nding
and is found in 0.3 – 2.7% of patients with chronic
subdural haematomas.3,4 When it occurs bilaterally
it gives the typical appearance of an “armoured
brain”.5 It occurs more frequently in children and
young adults as a long term sequelae of ventriculo-
peritoneal shunt insertion in childhood.6 e
diagnosis is usually made with the aid of a CT scan
or an MRI. ese calcications are mostly found
at the convexities.7 Observation is commonly
recommended for elderly asymptomatic CCSDH
without acute or progressive neurological disorders.
Although surgical treatment for symptomatic
CCSDH is widely accepted, there is still some
controversy whether it should be used and what
procedure to be followed.3
Case presentation
A 72 years old chronic alcoholic male presented in
our emergency with history of right-side weakness
for last ten days followed by unconsciousness for
last two days. He had repeated attack of fall in recent
past. e non-contrast computed tomography
(CT) scans documented a large chronic subdural
collection of the le hemisphere, with a large
CCSDH in right fronto parietal region leading to
signicant brain compression (Figure 1).
Le frontal and parietal burr hole and evacuation
of CSDH with thorough irrigation of subdural space
and subdural closed drain insertion was performed
fast followed by, right frontoparietal craniotomy was
performed with craniotomy margin exciding 1cm
beyond the calcied lesion all-around. Armored
dura with the mould of the underlying CCSDH
was exposed. Dura hitching stitches were placed
in the extradural space. e dura was opened in an
arcuate manner, exposing the calcied wall of the
chronic subdural haematoma (Figure 2), which
was tightly adherent to the inner surface of the
dura. Aer dissecting dura, the margin of loculated
CCSDH was delineated. It was found to be attached
to a non-calcied vascular membrane of CCSDH
(Figure 3).
39
Published by DiscoverSys | IJN 2019; 2(2): 38-41 | doi: 10.15562/ijn.v2i2.35
CASE REPORT
e non-calcied membrane capsule was
cauterized and incised in a circumferential manner.
Aer making it free from its dural attachment
the loculated CCSDH was exposed overlying the
parenchyma surface. e arachnoid membrane was
intact and not adhered to the CCSDH, allowing for
its in toto removal without injuring the underlying
brain (Figure 3 and 4). e excised loculated
CCSDH was fractured and opened to found
containing clear water. Post-operative he regained
his conscious level and right-side weakness
improved. Post-operative CT scan documented
expansion of brain on either side (Figure 5).
Discussion
In present day, development of medical science
has provided us better understanding of various
disease.8 However, the pathogenesis of CCSDH is
unclear, the haemorrhage is thought to progress
from hyalinization to calcication but it has been
found that it takes at least six months for calcication
to develop.7 Abnormal inherent metabolic tendency
to calcication can play a role in calcication.1
However, the mechanism of calcication is still
unclear and the periods of calcication are quite
dierent. Patients can present with hemiparesis,
aphasia, seizure, gait disturbances, mental and
physical retardation and altered consciousness.
However asymptomatic cases have also been
reported.9 It has been suggested that the presence of
brain atrophy may have been the reason why some
Figure 3. Intra operative image showing non calcied vascular
membrane of CCSDH (blue arrow head) attached
to inner surface of dura with an intact arachnoid
membrane (black arrow head)
Figure 1. e non-contrast computed tomography (CT) scan
showing a large CSDH of the le hemisphere, with a
large CCSDH in right hemisphere leading to signicant
brain compression
Figure 2. Intra operative image showing reected dura (blue
arrow head) with underlying loculated calcied
chronic subdural haematoma (black arrow head)
40 Published by DiscoverSys | IJN 2019; 2(2): 38-41 | doi: 10.15562/ijn.v2i2.35
CASE REPORT
cases are asymptomatic. Other conditions that can
be considered to mimic CCSH are calcied epidural
haematoma, calcied chronic subdural empyema,
meningioma, and calcied arachnoid cyst. e
surgical strategies dependents upon the thickness
and extent of calcication. e calcications have
been reported mostly along the inner surface of
dura mater. However, calcication of both outer
and inner layers in bilateral chronic SDH has also
been reported.1 In one case, the author was able to
peel o the calcied inner layer easily, the thickness
of calcication in that case was 4 to 5 mm.10 In cases
where the thickness and extent of calcication is
more, some neurosurgeons recommended drilling
of the calcied layer above the inner membrane.2
Our case is dierent from other cases as we were
able to excise it in toto despite a thick calcied
portion.
CONCLUSION
From our experience with present case we conclude
that such well loculated calcied thick CSDH can
be safely excised in toto if following points are taken
care. First, craniotomy is properly planned to expose
a healthy dural margin of 1 cm beyond calcied
lesion all around. Second, non-calcied vascular
membrane of CSDH attached to margin of CCSDH
are cauterized before incised. ird, care taken
during dissection of CCSDH from parenchymal
surface preserving the arachnoid. Further study
regarding the pathogenesis of CCSDH may help us
in preventing the development of this unique entity.
AUTHOR’S CONTRIBUTION:
Includes literature review, manuscript preparation
and editing. e manuscript has been approved by
all authors to be submitted and published.
CONFLICT OF INTEREST:
ere is no potential conict of interest relevant to
this article reported.
FUNDING:
No specic funding was provided for this article.
PATIENT CONSENT:
is study obtained patient consent directly from
the patient.
Figure 4. In toto excised specimen of CCSDH
Figure 5. Immediate post-operative CT scan showing expansion
of brain on either side with le side pneumocephalous,
which resolved spontaneously
41
Published by DiscoverSys | IJN 2019; 2(2): 38-41 | doi: 10.15562/ijn.v2i2.35
CASE REPORT
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