DOI: 10.5137/1019-5149.JTN.4782-11.1

Şant Cerrahisinden Sonra Hidrosefali ile Zırhlı Beyin:
Literatür Taraması
Mahmoud M. Taha
Zagazig University Hospitals, Department of Neurosurgery, Zagazig, Egypt
Correspondence address: Mahmoud M. Taha / E-mail: [email-masked]

ABSTRACT
Armored brain or chronic calcified subdural hematoma is a rare complication of cerebrospinal fluid diversion with few cases reported in the
literature. Seventeen patients with this pathology have been published. A complete review of the literatures regarding this topic has been
collected and discussed. The author also presents a 12- year old boy with triventricular hydrocephalus who had undergone ventriculoperitoneal
medium pressure shunt system since birth. The patient presented to our clinic with a 2-year history of seizures. The patient was conscious
and without neurological deficits on examination. Computed tomography of the brain showed bilateral high density mass with surface
calcification. X ray skull and MRI confirmed the calcified subdural hematoma bilaterally. We preferred conservative treatment and the patient
continued his antiepileptic treatment. At one year follow up, the patient had the same neurological state. The case highlights the importance
of frequent follow up CT brain after shunt surgery.
Keywords: Armored brain, Subdural hematoma, Hydrocephalus, Ventriculoperitoneal shunt, Complications

ÖZ
Zırhlı beyin veya kronik kalsifiye subdural hematom serebrospinal sıvı diversiyonunun nadir bir komplikasyonudur ve literatürde sadece birkaç
vaka vardır. Bu patolojinin bulunduğu on yedi hasta bildirilmiştir. Bu konuyla ilgili literatür tam olarak gözden geçirilmiştir ve burada yer
almaktadır. Yazar ayrıca triventriküler hidrosefalisi olan ve doğuştan beri ventriküloperitoneal orta basınçlı bir şant sistemi bulunan 12 yaşında
bir erkek hastayı sunmaktadır. Hasta kliniğimize 2 yıldır havale öyküsüyle başvurdu. Hastanın bilinci açıktı ve incelemede herhangi bir nörolojik
defisit yoktu. Beyin bilgisayarlı tomografisi yüzey kalsifikasyonlu bilateral yüksek dansiteli bir kitle gösterdi. Kafa filmi ve MRG bilateral kalsifiye
subdural hematomu doğruladı. Konservatif tedaviyi tercih ettik ve hasta antiepileptik tedavisini kullanmaya devam etti. Bir yıllık takipte
hastanın nörolojik durumu aynıydı. Vaka şant cerrahisinden sonra sık beyin BT ile takibin önemini vurgulamaktadır.
ANAHTAR SÖZCÜKLER: Zırhlı beyin, Subdural hematom, Hidrosefali, Ventriküloperitoneal şant, Komplikasyonlar

Introduction
In 1884, Von Rokitansky described calcified chronic subdural
as a finding at autopsy (23). Goldhan reported the first case
of armored brain or calcified chronic subdural hematoma in
1930 (15). This was an 11-year-old child with the typical dense
shadow of calcification under the cranial vault on the left side
(8). Calcifications occur in the membranes of chronic subdural
hematoma in the range of 0.3% to 2.7% (5, 10, 18). Although
usually seen in posttraumatic subdural hematoma, they have
been reported in patient with post-meningitic effusion and
in patients with hydrocephalus after ventriculoperitoneal
shunt (10). This article reported a 12-year-old patient
with bilateral calcified chronic subdural hematoma after
ventriculoperitoneal shunt for management of congenital
hydrocephalus as well as a review of the literature for similar
cases.
Case report
A 12-year-old boy was admitted to our outpatient clinic with
Turkish Neurosurgery 2012, Vol: 22, No: 4, 407-410

history of seizures 2 years ago. The patient received medium
pressure ventriculoperitoneal shunt at birth at another
hospital for his congenital hydrocephalus. According to his
family; the patient had a smooth and uneventful course
but showed low school performance which was accepted
by the family. The family stopped follow up with time as
the patient was asymptomatic. 2 years ago, the patient
started have seizures that were treated with antiepileptic
drugs by the family doctor without asking for computed
tomography. The patient presented at our outpatient clinic
and his neurological examination revealed normal findings
with delayed filling at the VP shunt reservoir. The patient was
not complaining from symptoms of increased intracranial
pressure. Computed tomographic examination of the brain
showed bilateral calcified chronic subdural hematoma
(Figure 2A-D). MRI brain and x ray skull were also performed
to confirm the diagnosis of calcified hematoma (Figures 1A,B;
3A,B). We choose conservative treatment as we do not believe
that epilepsy will improve with surgery. At one year follow

407

Review

Armored Brain in Patients with Hydrocephalus after
Shunt Surgery: Review of the Literatures

Taha MM: Armored Brain in Patients with Hydrocephalus after Shunt Surgery

up; the patient showed no symptoms or signs of increased
intracranial pressure, with the same visual acuity and school
performance.
Review of the literature
Including the current study, 18 cases with calcified chronic
subdural hematoma in patients after ventriculoperitoneal or
ventriculoatrial procedures were reported in the literature to
the best of our knowledge as shown in table (1). The patients
consisted of 5 females and 13 males. Their ages ranged from
10 months to 43 years. 4 patients were asymptomatic and
discovered incidentally during routine imaging after shunt
surgery, while 14 patients were symptomatic. Craniotomy was
performed in 8 patients while the remaining 10 patients were
treated conservatively. All patients treated conservatively
maintained their neurological status without deterioration,
while the remaining 8 patients treated with craniotomy
showed stable neurological status or slight improvement.
Discussion
Armored brain or Matrioska head is an adhering calcification
extending to the cerebral cortex corresponding to the inner
membrane of chronic subdural hematoma (18). In such a
pathology that reflects the computed tomogram finding, there
appears to be another concentric skull inside the cranium (18).
It is more commonly seen in children although it has been

A

b

Figure 1A,B: X ray skull AP and lateral views show bilateral
thickening of the skull in the frontal region.

A

b

reported in all age groups (10, 18).The clinical presentation
varies from patients who are asymptomatic to those with signs
of increased intracranial pressure, seizures, mental retardation
or even transtentorial herniation (5, 17). Epilepsy may occur
several years after a shunt operation as in our patient who
suffered from epilepsy 10 years after his operation. Amr et
al in their case report described a 30-year-old female patient
who had epilepsy 29 years after shunt operation (2). The
asymptomatic cases after ventriculoperitoneal shunt may be
due to sufficient CSF drainage that compensates the raised
intracranial pressure (1).The presence of calcification after
hematoma was identified at intervals of months and several
years (1, 16). However, Iwakuma and Brunngraber reported
microscopic signs of ossification on the 9th day after head
injury in a 9-month-old baby (12). The precise mechanism of
calcifications remains unclear. Microscopic calcium deposits
can be seen within the membranes of chronic subdural
hematoma. In some cases these deposits may proceed to
extensive calcification and even ossifications. Poor circulation
and delayed resorption of the hematoma fluid within the
subdural space are blamed (1). An underlying metabolic
abnormality as an inherent tendency to calcification in
patients with parathyroid disorders has been postulated (4).
The calcification develops primarily on the dural side of the
hematoma so the outer layer of the capsule is usually thicker
(12) Subdural collection due to rapid lowering of intracranial
pressure is a well known and rare complication after CSF
diversion procedures (19). Several precautions are required
to minimize the subdural collections after CSF diversion
procedures including minimal CSF leak at the time of
ventricular catheter insertion, use of medium, high pressure
or programmable valves, slow return to upright position and
close follow up including postoperative CT (19). Preoperative
diagnosis of calcified chronic subdural hematoma is important
for the selection of proper therapeutic strategy (10, 13). The
combination of CT and MRI brain is very useful in making
the diagnosis. Calcification of the membranes of subdural
hematoma appears as bone on the computed tomography
as in our patient, while organized or partially calcified lesions
appear as heterogenous moderate high density areas on CT
and as mixed areas of low and high intensity lesions on T1weighted MR imaging, with heterogenous web or net-like
appearance in the hematoma cavities. T2-weighted imaging
also shows the calcification as a characteristic heterogenous

c

d

Figure 2A-D: Computed tomography of the brain axial cuts show the bilateral calcified subdural hematoma and its extension.

408

Turkish Neurosurgery 2012, Vol: 22, No: 4, 407-410

Taha MM: Armored Brain in Patients with Hydrocephalus after Shunt Surgery

A

Figure 3: A) Axial T2weighted MRI showing the
bilateral calcified subdural
hematoma.
B) Coronal T1-weighted
MRI showing the calcified
subdural hematoma of
different intensity.

b

Table I: Armored Brain in Patients with Hydrocephalus after Shunt Surgery in the English Literature

Age and
sex
6y-F

Study

No

Takaku and Komatsu,197322)

1

Tvete and Larsen, 197822)

2

5y-M
7y-M

Mori ,1982 15)

1

5y-M

Ludwig, 198313)

3

8y-M
3y-F
18y-F

Gandolfi, 1983 7)

1

12y-M

Barmeir, 19853)

2

Spadaro, 198721)

1

Sharma, 1999 20)

2

Al Wahaib, 2003 1)

Symptoms

Type of
shunt
VA

Treatment

Outcome

Surgery

GR

VA
VA

Surgery
Surgery

ND
ND

VP

surgery

GR

ND
ND
ND

conservative
conservative
Surgery

GR
GR
GR

VA

surgery

GR

conservative

GR

conservative
Surgery
Surgery

GR
GR
GR

15y-F
10y-M
13y-M
9y-M
10y-M

mental retardation
seizures
mental retardation,
increased ICP
right hemiparesis, mental
retardation
asymptomatic
epilepsy
asymptomatic
headache, vomiting,
apathy
headache, vomiting
asymptomatic
gait disturbance
vomiting, disturbed
consciousness

1

10m-M

asymptomatic

VP

conservative

GR

He XS, 2005 9)

1

15y-M

headache, right
hemiparesis, urinary
incontinence

VP

Surgery

GR

Dimogerontas, 20066)

1

43y-M

headache, vomiting

VP

Papanikolaou, 200818)

1

33y-M

Increased ICP

VA

Amr, 2008 2)
Current study

1
1

30y-F
12y-M

Epilepsy
Epilepsy

VP
VP

VP,
VA
VA
VP
VP

conservative
(shunt revision)
conservative
(shunt revision)
Conservative
Conservative

GR
GR
GR
GR

Abbreviations in Table I: GR; Good recovery, ICP; Increased intracranial pressure, F; Female, m; month, M; Male, ND; No data, VA; Ventriculoatrial,
VP; Ventriculoperitoneal, Y; Year

Turkish Neurosurgery 2012, Vol: 22, No: 4, 407-410

409

Taha MM: Armored Brain in Patients with Hydrocephalus after Shunt Surgery

structures (10). The management of calcified chronic subdural
hematoma is a matter of controversy and it is recommended
that surgical intervention should be limited to patients
who have progressive neurological deficits or evidence of
increased intracranial pressure (18). The surgical intervention
for calcified chronic subdural hematoma has no effect on
the long term brain atrophy and the symptoms are related
to that brain damage rather than the calcified mass as in our
patient with epilepsy. MacLaurin and MacLaurin (14) reported
no improvement in the IQ of their 6 children after surgery.
Iplikcioglu et al in their patient showed seizure control after
surgery but the patient continued his anti epileptic treatment
(11). Moreover, the commonly atrophic parenchyma after
discharged from its armor is not liable to expand completely
so the increased brain volume will not be enough to prevent
accumulation of subdural hygroma. Ludwig et al (22), in
their only patient treated surgically because of disturbed
consciousness after cranial trauma, reported that the increase
in brain volume was only moderate after surgery and the
patient required shunting of the recurrent subdural hygroma.
We did not believe that removal of such lesions were necessary
or beneficial for our patient
Disclosure
The author report no conflict of interest concerning the
materials or methods used in this study or the findings
specified in this paper.
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