Keywords
chronic subdural hematoma - chronic calcified subdural hematoma - third nerve palsy
- chronic subdural hematoma with fungus-like mass
Introduction
The article by Kumar and Alugolu[1] described atypical neurologic presentation of the chronic subdural hematoma (SDH)
in 2014, which confirms the statement that the medicine is not like mathematics. Sometimes
radiologic findings do not correlate with neurologic symptom; therefore, every patient
is to be considered individually for correct management.
A widely accepted classification divides SDHs into acute, subacute, and chronic according
to the time elapsed between the head injury and the onset of clinical symptoms.
Here we present three patients with chronic SDH, with each case having its unique
presentation.
Aim and Objective
Calcified chronic SDH is a rare but known entity. It has been estimated to represent
0.3 to 2.7% of chronic SDHs, since its first description in 1884. Since then, approximately
100 cases have been reported till date.
Chronic SDH cases also present in various modes. Here we present three unusual cases
of chronic SDH that help us know the divergence of different clinical and imaging
characteristics of chronic SDH.
Case 1
A 60-year-old nondiabetic, nonhypertensive, and nonalcoholic male patient presented
to emergency with history of sudden-onset loss of consciousness and fall with left-sided
hemiparesis, with Glasgow coma scale (GCS) of E1V1M2 with left hemiparesis and right-sided
complete third nerve palsy. Urgent computed tomographic (CT) scan of the brain plain
revealed hyperdense biconvex extra-axial lesion in the right temporoparietal region
([Fig. 1]), which is very much suggestive of acute extradural hematoma (EDH), but history
of trivial trauma following unconsciousness leads us to some amount of confusion regarding
the pathology. We went for emergency right-sided fronto-temporo-parietal craniotomy
that revealed no evidence of EDH, but the dura was found to be tense. Durotomy was
done, which revealed semisolid hematoma with muddy consistency and having gritty sensation.
Whole of the hematoma evacuated inner membrane also excised here as it was calcified.
The patient's GCS and left hemiplegia improved to the power of 4/5 within 48 hours
of operation. Right third nerve palsy persisted. In 6-week follow-up, the patient
became completely ambulatory with complete recovery of left hemiplegia and partial
recovery of right third nerve palsy.
Fig. 1 (A) Preoperative CT scan showing hyperdense biconvex extra-axial lesion in right parietal
region. (B) Postoperative image showing complete evacuation of SDH with remnant of membrane.
(C) A 6-week F.U. image of patient with partial recovery of right third nerve palsy.
CT, computed tomography.
Case 2
A 30-year-old male patient with history of ventriculoperitoneal (VP) shunt at age
of 5 years presented with imbalance, lower limb weakness, and discharging pus from
the right forehead at OPD. CT scan revealed bilateral biconvex hypodense extra-axial
lesion with hyperdense wall. Bilateral craniotomy was planned, which revealed subdural
collection with fungus-like material embedded in the inner membrane and communicating
with sinus tract of the scalp. Subdural collection with mass was evacuated, and inner
membrane was removed ([Fig. 2]). Postoperatively, the patient developed sepsis on sixth postoperative day and succumbed
due to septicemia.
Fig. 2 (A, B) Preoperative CT showing bilateral biconvex extra-axial lesions with calcified wall.
(C) Intraoperative image showing subdural collection with fungus-like mass. CT, computed
tomography.
Case 3
A 10-year-old girl presented with recent-onset headache and left-sided hemiparesis
for 1 week. She had a history of shunt surgery for congenital hydrocephalus at age
of 6 months. CT scan showed right-sided extra-axial biconvex lesion with calcified
wall. Craniotomy showed thickly calcified chronic calcified SDH and whole of the calcified
mass was excised ([Fig. 3]). Excised specimen showed shell-like mass with the outer and inner membrane being
calcified within which there was collection of fluid. Postoperatively, the patient
recovered well, left hemiparesis improved, and the patient was discharged on 10th
postoperative day.
Fig. 3 (A) Preoperative CT showing extra-axial lesion with calcified wall. (B) Intraoperative image of excised mass with both side calcified in between that the
fluid was present. CT, computed tomography.
Discussion
Although surgical treatment is unanimous for chronic SDHs, therein lies some doubt
on it being applied to calcified chronic SDHs. The optimal surgical procedure for
this type of lesion, classically referred to as “armored brain,”[2] has not been established due to the limited reexpansion of the brain after surgery.
This is probably related with the presence of a thick calcified inner membrane, which
is frequently adherent to the cortical surface of the parenchyma.[3] Surgical removal of the calcification is difficult, and it could damage the underlying
cortex. Hence it should not be performed routinely.[3] Treatment of a symptomatic expanding hematoma in these cases presents the treating
physician with a difficult problem, and it may require a somewhat different approach
from usual.
Removal of the calcified chronic SDH reduces the mass effect and cerebral irritation
and increases the cerebral blood flow; thus, patients can improve neurologically after
surgery.[4]
In all these cases, the typical imaging characteristics of chronic SDH were not found;
rather, imaging characteristics of all three cases were more like extradural mass.
In all these cases, craniotomy was needed rather than burr hole and evacuation, which
is the most common treatment for chronic SDH.[5]
In these three cases, there was one mortality and other two patients recovered from
their symptoms.
Conclusion
Chronic calcified SDH are rare entities, which are well tolerated due to their indolent
nature even though the radiologic findings might be quite impressive and without direct
clinical correlation.
In all three cases, we found different clinical, radiologic, and intraoperative picture.
These cases often create confusions and dilemma in treatment modality, but in our
experience two out of three cases improved with surgical evacuation of the long-standing
chronic SDH.
