Images in Pediatric Neurosurgery Pediatr Neurosurg 2008;44:88–89 DOI: 10.1159/000110672 ‘Armoured Brain’ A Case Report of a Calcified Chronic Subdural Haematoma Romel Amr Loaie Maraqa Qaiser Choudry Department of Neurosurgery, Royal Preston Hospital, Fulwood, Preston, UK Introduction Case Report Epilepsy and subdural haematomas are known complications of shunt-treated hydrocephalus [1]. However, calcification of a chronic subdural haematoma after ventriculoperitoneal shunting is rare [2–6]. When extensive, the calcification resembles a shell encasing the brain, hence the term ‘armoured brain’ [5]. We describe a case of a calcified chronic subdural haematoma in a patient presenting with epilepsy 29 years after ventriculoperitoneal shunting. A 30-year-old female patient, known to have spina bifida and congenital hydrocephalus, was treated with ventriculoperitoneal shunting at the age of 9 months. She was referred to our neurosurgical department with new-onset seizures during which she was vague and incoherent, with no reported loss of consciousness. The original shunt was never revised. Clinical findings included increased head circumference and nystagmus in all areas of gaze. The patient was paraplegic with an indwelling urinary catheter. Biochemical markers were normal. A CT scan showed a calcified subdural haematoma within the left occipitoparietal region, causing effacement of the left lateral ven- Fig. 1. a CT showing a 10 ! 8 ! 5.5 cm calcified subdural haematoma in the left occipitoparietal lobe. b Tip of ventriculoperitoneal shunt in right lateral ventricle. © 2008 S. Karger AG, Basel 1016–2291/08/0441–0088$24.50/0 Fax +41 61 306 12 34 E-Mail karger@karger.ch www.karger.com Accessible online at: www.karger.com/pne Romel Amr Royal Preston Hospital Sharoe Green Lane Fulwood, Preston PR2 9HT (UK) Tel. +44 177 271 6565, Fax +44 177 252 2333, E-Mail romelamr@msn.com tricle, dilated lateral ventricles and a universally thickened skull vault (fig. 1a). The shunt position was adequate (fig. 1b) with no evidence of malfunctioning. EEG studies showed a focal epileptogenic focus at the left parietal lobe and therefore sodium valproate treatment was initiated. No surgical intervention was indicated and CT findings remained unchanged over a 1-year follow-up period. The patient had no further seizures and remains well after 2 years. Discussion In children, the risk of subdural haematomas after ventriculoperitoneal shunting ranges from 2.8 to 5.4% [1].The frequency of radiologically apparent calcifications in these haematomas is reported to range from 0.3 to 2.7% [2]. The pathogenesis and mechanisms of calcification remain unclear. 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]. References ‘Armoured Brain’ 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 [3–6]. Surgery is beneficial in the subgroup of symptomatic patients presenting with either acute or progressive neurologies or those with acutely raised intracranial pressures [5–6]. In contrast, seizure control can be successfully achieved with conventional anticonvulsant therapy, whilst some authors have reported improved control with surgical excision [6]. Conclusion Calcified subdural haematomas after ventricular shunting are rare. Management is guided by the clinical presentation. As ventricular shunting may carry longterm complications, we suggest interval CT scans to be considered in the follow-up of such patients. 1 Puca A, Fernandez E, Colosimo C, Lauretti L, Pallini R, Tamburrini G: Hydrocephalus and macrocrania:, surgical or non-surgical treatment of the postshunting subdural hematoma. Surg Neurol 1996;45:376–382. 2 Niwa J, Nakamura T, Fujishige M, Hashi K: Removal of a large asymptomatic calcified subdural hematoma. Surg Neurol 1988; 30: 135–139. 3 Afa D: Ossification of subdural hematoma: report of two cases. J Neurosurg 1961; 18: 393–397. 4 Sharma RR, Mahapatra A, Pawar SJ: Symptomatic calcified subdural hematomas. Pediatr Neurosurg 1999;31:150–154. 5 Al Wohaibi M, Russell N, Al Ferayan: A baby with armoured brain. CMAJ 2003; 169: 46– 47. 6 Yan HJ, Lin KE, Lee ST, Tzaan WC: Calcified chronic subdural hematoma: case report. Changgeng Yi Xue Za Zhi 1998;21:521–525. Pediatr Neurosurg 2008;44:88–89 89 Copyright: S. Karger AG, Basel 2007. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.