DOI: 10.5137/1019-5149.JTN.6189-12.1

Kronik Subdural Hematom ve Sefalhematom Kalsifikasyonları Nedeniyle
‘Çift Kafatası’ Görünümü: İki Olgu Sunumu
Vivek Tandon, Kanwaljeet Garg, Ashok Kumar Mahapatra
All India Institute of Medical Sciences, Department of Neurosurgery, New Delhi, India
Corresponding Author: Vivek Tandon / E-mail: [email-masked]

ABSTRACT
Chronic subdural hematomas and cephalhematomas are known to become calcified in some patients. We present interesting cases of
cephalhematoma in a child and calcified chronic subdural hematoma in an elderly lady with both getting calcified. The first patient was a 7
months male with calcified cephalhematoma who presented with cosmetic deformity of the skull but did not have any neurological deficits.
The other patient was a 54-year-old lady with calcified chronic subdural hematoma who presented with one episode of seizure but did not
have any neurological deficit. CT scan revealed calcification of the hematoma causing a double skull appearance in both patients.
Keywords: Cephalhematoma, Calcification, Subdural hematoma

ÖZ
Kronik subdural hematomlar ve sefalhematomların bazı hastalarda kalsifiye olduğu bilinmektedir. Bir çocukta sefalhematom ve yaşlı bir
kadında kronik subdural hematom bulunup her ikisinin kalsifiye olduğu ilginç olgular sunuyoruz. Birinci hasta kalsifiye sefalhematomlu 7 aylık
bir erkekti ve herhangi bir nörolojik kusur olmadan kafatasının kozmetik deformitesi nedeniyle geldi. İkinci hasta kalsifiye kronik subdural
hematomu olan 54 yaşında bir kadındı ve herhangi bir nörolojik defisiti olmadan bir nöbet episoduyla geldi. BT tarama her iki hastada çift
kafatası görünümüne neden olan kalsifikasyon gösterdi.
ANAHTAR SÖZCÜKLER: Sefalhematom, Kalsifikasyon, Subdural hematom

Introduction

Case report 1

Cephalhematoma occurs due to hemorrhage from ruptured
blood vessels that cross the periosteum of the skull. It is a
subperiosteal collection of blood and therefore has defined
boundaries and needs to be differentiated from caput
succedaneum and chignon, which are swellings of the scalp.
Calcification of the cephalhematoma can lead to persistent
scalp swelling in a child.

This 7 months male child had history of a fall at the age of 15
days after birth, following which the parents had noticed a
squishy swelling of the scalp in the parietal region. This swelling gradually became hard leading to abnormal appearance
of the skull. On examination, the child had no neurological
deficits. The scalp swelling was bony hard with well-defined
margins. His computed tomography image revealed a calcified swelling of the scalp, giving a double skull appearance
(Figure 1). A diagnosis of calcified cephalhematoma was
made.

Similarly, calcification of a chronic subdural hematoma is
more frequently seen in children and young adults than
in the aged (5). Seizures and mental retardation are more
common symptoms of calcified chronic subdural hematomas
in children, while they may present with mild symptoms or
may even remain asymptomatic in adults (4).
We present two interesting cases of post-traumatic cephalhematoma and chronic subdural hematoma, in a 7 months child
and a 54-year-old lady respectively. Calcification of these hematomas gave a double skull appearance on their CT scan.

Turkish Neurosurgery 2013, Vol: 23, No: 6, 815-817

Case report 2
This 54-year-old lady presented with a history of one episode
of generalized tonic clonic seizures but with no neurological
deficits. On being probed, she gave a history of minor trauma
to the head about 2 years back. Her CT scan revealed a
calcified chronic subdural hematoma with midline shift to the
opposite side, with open cisterns and easily seen sulci and gyri
(Figure 2). This patient had no neurological deficits; therefore

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Case Report

‘Double Skull’ Appearance due to Calcifications of
Chronic Subdural Hematoma and Cephalhematoma:
A Report of Two Cases

Tandon V. et al: “Double Skull’ Appearance

she was managed conservatively on antiepileptic drugs and
had no recurrence of seizures at one-year follow-up.
Discussion
The usual causes of cephalhematoma are prolonged second
stage of labor or instrumental delivery, particularly after

ventouse application (3). The child may develop jaundice,
anemia or hypotension due to the hematoma. The swelling
is usually resolved over a week as the blood clot gets slowly
absorbed. At times the hematoma can get calcified, leading
to a hardened mass of the skull. The collection of blood
is subperiosteal in cephalhematoma. On the other hand,

Figure 1: Computed tomography scan of 7-month-old male child showing calcified cephalhematoma giving rise to a ‘double skull’
appearance.

Figure 2: CT scan of a 54-year-old lady showing calcified subdural hematoma producing an appearance of ‘double skull’.

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Turkish Neurosurgery 2013, Vol: 23, No: 6, 815-817

Tandon V. et al: “Double Skull’ Appearance

subgaleal collections of blood (caput succedaneum and
chignon) are due to collection of blood in the loose areolar
tissue between the galea and the periosteum. They can dissect
a large area and cross suture lines. Cephalhematoma causes
stripping of the periosteum layer that is limited to the sutures
where the periosteum is densely adhered. This elevated
periosteum can calcify and consequently such lesions can
be misdiagnosed as intraosseous hematomas, arachnoid
cysts, granulomatous lesions, or meningoencephaloceles
(6,7). Radiological studies like CT scan, MRI and even plain
and tangential X rays of the skull are helpful in differentiating
the above lesions. CT scan of intraosseous hematomas
demonstrates isodense areas while cephalhematomas tend
to be hypodense to hyperdense and can resemble depression
fractures if palpated. In their comparison, cephalhematoma
is limited by suture lines and can be associated with linear
fractures of the skull. Intraosseous hematomas on MRI are
hypointense on T1- and hyperintense on T2-weighted images,
but this is insufficient for differentiation. Rarely, biopsy may
be needed to know the exact cause of scalp swelling (1).
Surgical resection of cephalhematoma is needed either for
the above reason or for cosmetic purposes. Radiological
follow up can be considered for calcified cephalhematomas,
at least for a few months, because even spontaneous
resolution has been reported in literature. Spontaneous
resolution is explained by the tendency of the cranium under
the ossified subperiosteum to grow, which gradually fills the
space between the periosteum and cranium (1).
Radiologically demonstrable calcification of the chronic
SDH membrane occurs in 0.3-2.7% cases of chronic SDH (8).
An adhering calcification extending to the cerebral cortex
corresponding to the inner membrane of chronic SDH is
also called “armoured brain” (2) or “Matrioska head”(9). These
names are given because the computed tomogram scan
resembles a picture of another concentric skull inside the
cranium. This is usually seen in subdural hematomas but
can occur in postmeningitic subdural effusions as well (10).
Development of calcification in hematoma may vary from 6
months to many years (8,10). The underlying mechanism of
calcification in these patients is unclear (2), and the presenting
complains can range from being asymptomatic to those of
raised intracranial pressure as well as seizures and mental
retardation (10). Routine removal of these is not advocated
as the surgical removal of the calcification is difficult and can

Turkish Neurosurgery 2013, Vol: 23, No: 6, 815-817

cause damage to the cortex. The treatment of symptomatic
expanding hematoma in these cases presents a challenge
and may require a different approach than usual (2). Our
patient had calcified chronic SDH that had failed to resolve
but she had no neurological deficit and she was therefore
treated conservatively (2).
Minor trauma to head was present in both of our patients
history and it is likely that the cephalhematoma and chronic
SDH might have become calcified and thus produced an
interesting picture of a skull within a skull.
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