Armored brain in patients with hydrocephalus after shunt surgery; review of the literatures

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 ÖZZırhlı 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.

Armored brain associated with secondary craniostenosis development at 7-year following ventriculoperitoneal shunt surgery during infancy: Extremely unusual association and review

“…A calcified chronic subdural hematoma (CCSDH) is extremely uncommon occurrence. [ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 ] Calcification in a traumatic subdural hematoma is relatively more common than the subdural collections of postmeningitic and VP shunt origin. It is more frequently seen in children though it has been described in all age groups.…”

“…In 2012, Taha could able to collect only ten cases of isolated CSSDH, occurring following shunt surgery, in his detailed literature search, who developed during the very first decade of life, but none of the analyzed cases had additional association of secondary craniostenosis. [ 2 ] The exact mechanism of osseous transformation is lacking. Many postulates are put forward to explain the pathogenesis of CCSDH including injury to the highly vascular tissues, i.e., dura matter, skull bones provoking inflammatory response and although healing is comparatively more rapid in children than the adult counterpart.…”

“…Calcification is considered uncommon in chronic subdural hematoma and observed in about 0.3%–2.7% of cases of chronic subdural hematoma. [ 1 2 ] This complication has been rarely reported in cases suffering with hydrocephalus treated with shunt surgery. [ 1 3 4 ]…”

Armored brain in a young girl with a syndromal hydrocephalus

“…This condition is diagnosed by the presence of hyperdense outer and inner rims separated by a slightly hypodense area on CT [3]. This phenomenon is pathognomonic and it is also known as ‘the matrioska effect’ [4]. The treatment is controversial, but surgical therapy might be an option if the condition leads to mass effect and raised intracranial pressure [5].…”

Anesthetic management of a case of armored brain

“…Armored brain is a rare complication of VP shunt first reported by Goldhen in 1930, and only few cases of armored brain are reported in the literature. [ 1 ] Calcified chronic subdural hematoma (SDH) is rare, but if occurs bilaterally, it gives the appearance of an armored brain, so-called because the calcified subdural collection appears as “bone under bone” or “double skull.”[ 2 ] On computerized tomographic scan (CT scan) if a shell carapace is encasing the brain, it also known as “Matrioska head”[ 2 ]…”