RESIDENT & FELLOW SECTION Section Editor Mitchell S.V. Elkind, MD, MS A. Dagain, MD A. Faivre, MD T. Lafolie, MD D. Wybrecht, MD C. Joubert, MD P. Alla, MD R. Dulou, MD Teaching NeuroImages: Armored brain Figure Armored brain: Calcified chronic subdural hematoma from shunting overdrainage Correspondence & reprint requests to Dr. Dagain: dr.adagain@gmail.com (A) Axial nonenhanced head CT scan demonstrates ventricular enlargement with shunting drain and a calcified pan hemispheric subdural hematoma (arrows). (B) Coronal nonenhanced head CT scan shows bilateral calcification of inner membrane of subdural hematoma (arrows). A 20-year-old man was admitted with several epileptic seizures. At age 4 months, he had presented with hydrocephalus heralding a benign pineal tumor, and underwent ventriculoatrial shunting. Afterwards, he no longer sought medical care. On admission, the physical examination demonstrated a large head circumference and a chronic right hemiparesis. A CT scan revealed a calcified chronic subdural hematoma (figure, A and B).1 Surgical intervention was withheld in favor of medical management with antiepileptic medications. He reports no further seizures. The proper management of calcified chronic subdural hematoma is unclear,2 but our observations suggest that medical treatment seems to be more appropriate than surgical therapy in adults without intracranial hypertension. AUTHOR CONTRIBUTIONS Dr. Dagain participated in the writing and design of the article. Dr. Faivre participated in the writing and design of the article. Dr. Lafolie participated in the writing and design of the article. Dr. Wybrecht participated in the writing and design of the article. Dr. Joubert participated in the writing and design of the article. Pr. Alla participated in the writing and design of the article. Pr. Dulou participated in the writing and design of the article. REFERENCES 1. Dammers R, ter Laak-Poort MP, Maas Al. Armoured brain: case report of a symptomatic calcified chronic subdural haematoma. J Neurol Neurosurg Psychiatry 2007;78:542–543. 2. He XS, Zhang X. Giant calcified chronic subdural haematoma: a long term complication of shunted hydrocephalus. J Neurol Neurosurg Psychiatry 2005;76:367. MYSTERY CASE RESPONSES The Mystery Case series was initiated by the Neurology® Resident & Fellow Section to develop the clinical reasoning skills of the trainees. Residency programs, medical student preceptors, and individuals were invited to use this Mystery Case as an education tool. Responses were solicited through a group e-mail sent to the AAN Consortium of Neurology Residents and Fellows and through social media. All the answers that we received for this Mystery Case came from individual residents rather than groups and they were all well-reasoned and thoughtful. The majority of respondents (75%) identified From the Neurosurgery Department (A.D., C.J., R.D.), Neurology Department (A.F., D.W., P.A.), and Radiology Department (T.L.), Sainte Anne Military Teaching Hospital, Toulon, France. Disclosure: The authors report no disclosures. Copyright © 2012 by AAN Enterprises, Inc. e39 the calcified chronic subdural hematoma and indicated shunt overdrainage as the putative mechanism of hematoma expansion. While all the respondents agreed on pharmacotherapy for seizures, there was controversy regarding the role of surgical treatment. Several surgical approaches were proposed including shunt revisions, hematoma drainage, and craniotomy for hematoma e40 Neurology 78 February 7, 2012 evacuation. This reflects the controversy that exists in the literature regarding the management of calcified subdural hematomas. This Mystery Case illustrates a rather rare etiology for epilepsy that may complicate ventricular shunting. Dragos A. Nita, MD, PhD The Hospital for Sick Children, Toronto