Large Chronic Calcified Subdural Hematoma with Empyema—A Long-Term Complication following Shunt Surgery

摘要

Chroniccalcified subdural hematoma(CCSDH) isarare but unusualentity and represents 0.3 to 2.7%ofchronicsubdural hematoma.1 2 Chroniccalcified SDHwas first described in literaturein 1884 byVonRokitansky3 asautopsy finding. Thiscomplication has been rarely reported inliterature withCSDH(chronicsubdural hematoma) following ventriculoperitoneal(VP) shunt for hydrocephalus. CCSDHareseen in posttraumaticsubdural hematomas, postmeningiticeffusion and in patients of hydrocephalus withVP shunt done.4 They areseen usually in children butareseen in allage groups.4 This type oflesion, isalso known asarmored brain or Matrioska head.5 Treatment ofchroniccalcified hematomas iscontroversial dueto limited reexpansion of brain after surgery thus recommending surgery onlywhen acute or progressive neurologicalsymptomsoccur.6 A25-year-old male presented with pus dischargefromleft parietalwound for past 10 years. Patientalso complained of headache on andofffor past 10 years. On examination, patient wasconscious, oriented,and with no neurological deficit. Patient was operated forcongenitalhydrocephalus ( Fig. 1A)at 4 years ofage, for which rightsided VP shunt was donein 1996. Patient was doingwell until he developed chronicsubduralempyema( Fig. 1B) in 1998, for which patient underwent left parietaland frontal burr hole with evacuation ofempyema. The patient wasasymptomaticforalmost 10 years. In 2008, patient developed pus dischargefromasinus in left parietalregion and underwent left parietalcraniotomywith debridementand drainage ofempyemacavity. But postoperatively patientcontinued to have pus dischargefromcavity. Patientwas lost to follow-up. During that period, hecontinued antiseptic dressing, till heagain reported in 2014. The patient wasevaluated withNCCThead, which revealed chroniccalcified subdural hematoma, with communicating cavity in left parietalregionwithVP shunt in situ ( Fig. 1C ).Patient wasadvised surgery but dueto unknown reasons herefused it. Patientcontinued to have pus dischargefromleft parietalwound. Hecontinued with antiseptic dressing at homealongwith antibiotics. Patientagain reported in 2018 for samecomplaintsand was planned for surgicalintervention. NCCT head revealed calcified chronicsubdural hematoma withmasseffectand midlineshift withmisplaced tip ofVP shunt in situ. Wound culture was sent,antibioticstarted according to culture,and when culturescamesterile, patient was taken up for surgery. Alargeleftfrontotemporoparietalflap was takenwith left frontotemporoparietalcraniotomywith removal ofchroniccalcified subdural hematoma with infectedboneflap was done. Calcified chronicsubdural hematoma was tightly adherent to inner surface of dura, butarachnoid was intactand notadherentto hematoma. Boneflap was sent for biopsy and culture which came out to besterile. The postoperative period was uneventful, patient recoveredfromchronicinfection. Postoperatively, patient was kept on empiricalcourse ofantibiotics for 6 weeks. Postoperativescan documentedreexpansion of brainwith resolution ofchroniccalcified subdural hematoma.