- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
Anthony L. Petraglia
Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
DOI:10.4103/2152-7806.84391Copyright: © 2011 Petraglia AL. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Petraglia AL, Moravan MJ, Jahromi BS. Armored brain: A case report and review of the literature. Surg Neurol Int 30-Aug-2011;2:120
How to cite this URL: Petraglia AL, Moravan MJ, Jahromi BS. Armored brain: A case report and review of the literature. Surg Neurol Int 30-Aug-2011;2:120. Available from: http://sni.wpengine.com/surgicalint_articles/armored-brain-a-case-report-and-review-of-the-literature/
Background:Calcified chronic subdural hematomas occur infrequently. When the calcifications are extensive and bilateral, the condition is termed “armored brain”. We describe a case of “armored brain” incidentally discovered in an adult presenting with abdominal pain and mild headaches, long after initial placement of a ventriculo-peritoneal (VP) shunt.
Case Description:A 38-year-old woman, treated at infancy with a VP shunt, presented with a 2-month history of abdominal pain associated with nausea and chills. She was neurologically intact on exam. An abdominal computed tomography (CT) scan demonstrated a rim-enhancing loculated fluid collection surrounding the patient's distal VP shunt catheter tip. As a part of her initial work-up, she received a head CT to evaluate the proximal VP shunt, which demonstrated large bilateral chronic subdural hematomas with heavily calcified walls. She was eventually taken to the operating room (OR) for replacement of the distal catheter. It was felt that her acute clinical presentation was unrelated to the bilateral, calcified subdural hematomas and thus the decision was made to manage them conservatively.
Conclusions:This rare complication of chronic shunting for hydrocephalus is sometimes referred to as armored brain. Surgery for armored brain is infrequently indicated and beneficial in only small subgroup of patients, with management guided by clinical presentation. Our patient fully recovered after shunt revision alone.
Keywords: Armored brain, calcification, subdural hematoma, ventriculo-peritoneal shunt
Chronic subdural hematomas are not uncommon; however, calcification or ossification in a chronic subdural hematoma occurs less frequently. Bilateral, calcified chronic subdural hematomas or “armored brain” has been reported in subdural hematomas of various etiologies, although rarely as a consequence of shunting for hydrocephalus.[
A 38-year-old woman with a history of obstructive hydrocephalus since infancy, treated with a VP shunt, presented with a 2-month history of abdominal pain associated with nausea and chills. She reported a long-standing history of occasional mild intermittent headaches since childhood as well. On physical examination, she was found to be neurologically intact. A computed tomography (CT) scan of her abdomen (not shown) revealed a large rim-enhancing, loculated fluid collection within the mid-abdomen, surrounding the patient's distal VP shunt catheter tip. These findings were concerning for pseudocyst formation.
The shunt was tapped and cerebrospinal fluid cultured. Her shunt was then subsequently externalized and her pseudocyst was drained by interventional radiology. The patient was kept on broad-spectrum antibiotics until all cultures returned negative and ultimately she was taken to the operating room at that time for replacement of the distal shunt catheter. As a part of her initial work-up, on admission, she received a head CT [Figure
Although chronic subdural hematomas are common, it is rare to observe calcification or ossification.[
Calcified chronic subdural hematomas have been reported most commonly as a late complication of traumatic brain injuries[
The clinical presentation of patients with “armored brain” is characterized by a slow progression of neurological signs and symptoms. While the majority of patients remain asymptomatic, symptoms can include gait disturbance, chronic headache, deteriorating vision, epileptic seizure, dysphasia, behavioral problems, paresis and even plegia.[
The pathogenic mechanisms underlying the calcification of chronic subdural hematomas remain poorly understood.[
Patient management is determined on an individualized basis. Patients who are asymptomatic, elderly or without progressive neurological deterioration may be managed conservatively with observation. Surgical intervention may be necessary in young patients or in situations where patients are clearly symptomatic from the calcified subdural hematomas. Although successful surgical removal has been described, it is frequently technically difficult to obtain complete excision.[
Here we report a patient, shunted from infancy, who presented with chronic mild headaches and acute findings consistent with a symptomatic abdominal pseudocyst. During the initial work-up, the patient was found to have “armored brain”. The patient's symptoms were successfully managed with VP shunt externalization, antibiotics, pseudocyst drainage and subsequent distal shunt revision. The extensive bilateral, calcified chronic subdural hematomas were managed conservatively. Management of this rare condition should be guided by clinical presentation, as surgery is beneficial in only a subgroup of patients.
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