Ossified chronic subdural hematoma

Ossified chronic subdural hematoma

Calcified chronic subdural hematoma or ossified chronic subdural hematoma (CSDH), characterized by slowly progressing neurological symptoms, is a rarely seen entity that may remain asymptomatic for many years.

Incidence of calcified or ossified CSDH is high in certain countries, including the USAJapan and Turkey, with a steady increase in recent years 1).

They should be considered in the differential diagnosis at the time when we encounter because of its infrequency and variable clinical manifestation, following shunting in children or head trauma in adults 2).

Differential diagnosis

Calcified epidural hematoma, calcified empyema, meningioma, calcified arachnoid cyst, and calcified convexity of the dura mater with acute epidural hematoma should be considered for the differential diagnosis 3).

Treatment

Management of CSDH has improved dramatically in recent years thanks to advances in diagnostic tools, but there is still some controversy regarding the optimal treatment strategy.

Systematic reviews

In a systematic review, PRISMA guidelines were followed to query existing online databases between January 1930 and December 2018. We found a total of 88 articles containing 114 cases of calcified or ossified CSDH, 83 patients operated and 31 ones not operated.

There were 78 males and 29 females (7 with unreported gender) from 25 countries, ages ranging from 4 months to 86 years (mean 33.7 years), with etiologies of head trauma in 33.3%, shunting for hydrocephalus in 27.2%, or following cranial surgery in 4.4%. The duration of symptoms ranged from acute onset to 20 years, with a mean of 24.1 months. Imaging techniques such as X-ray, computed tomography, and magnetic resonance imaging were used with pathological confirmation of CSDH and complete recovery in 56.4% of patients.

Incidence of calcified or ossified CSDH is high in certain countries, including the USAJapan and Turkey, with a steady increase in recent years. Therapy of choice is surgery in these patients and it should be considered in the differential diagnosis at the time when we encounter because of its infrequency and variable clinical manifestation, following shunting in children or head trauma in adults 4).


Yang X, Qian Z, Qiu Y, Li X. Diagnosis and Management of Ossified Chronic Subdural Hematoma. J Craniofac Surg. 2015 Sep;26(6):e550-1. doi: 10.1097/SCS.0000000000002025. PubMed PMID: 26352368.

Case reports

A 59-year-old man presented with epileptic seizures interpreted as episodic syncope in the past 3 years and the patient had a history of head trauma about 4 years ago. Computed tomography revealed an ossified chronic subdural hematoma involving the right frontotemporoparietal region, which was totally resected using microsurgical technique. Postoperatively, weakness developed in the right arm and magnetic resonance imaging revealed a bilateral tension pneumocephalus, which was immediately treated by a left frontal burr hole trepanation, and the patient was discharged uneventfully 5).


A 46-year-old man with a history of alcohol abuse and a right frontotemporoparietal and left frontal ossified CSH that was diagnosed 2 years previously presented with headache and memory loss over 6 days. The patient was being followed with serial imaging, which showed the static state of the mass and no other lesions 7 months before admission. He underwent right frontotemporoparietal craniectomy to remove the ossified CSH and tumor. When the bone was lifted and the thin dura was opened, a hard, thick, ossified capsule was observed. No apparent tumor invasion was noted in the skull or epidural space. Despite refusing further chemotherapy and radiation therapy, the patient has been disease-free and working for 5 years.

Based on reported cases and relevant literature, large B-cell lymphoma may be associated with ossified CSH 6).


A 81-year-old woman with calcified chronic subdural hematoma. The patient underwent an osteoplastic left craniotomy, evacuation of chronic subdural mass with careful dissection and successful removal of the inner and outer membrane. Postoperative CT scan showed removal of subdural hematoma, a decrease of the left shift of median line and good brain re-expansion. The postoperative period was without any serious complications.

The subdural hematoma was successfully removed, resulting in a good recovery with complete resolution of patient’s symptoms. They highly recommend surgical treatment in cases of chronic symptomatic calcified subdural hematomas 7).


A Giant Ossified Chronic Subdural Hematoma 8).


Fang et al. reported a case of ossified chronic subdural hematoma in a 7-year-old female child, with a literature review 9).


Siddiqui et al. reported one case with diabetes insipidus 10).


A young girl affected by a syndromal hydrocephalus who developed a bilateral ossified chronic subdural hematoma with the typical radiological appearance of “the armored brain”. Bilateral calcified chronic subdural hematoma is a rare complication of ventriculoperitoneal shunt. There is controversy in the treatment, but most published literature discourages a surgical intervention to remove the calcifications 11).


Turgut et al. published one Ossified chronic subdural hematoma 12).


A 22-year-old male who had presented with severe headache consequent to brain compression caused by bifronto-parieto-temporal ossified subdural hematoma. We evaluated our method and surgical intervention in the light of the literature. The question whether the ossified membrane should be excised or not excised in these cases is a matter of controversy. They think that an ossified membrane causing an armored brain appearance should be excised in symptomatic, young patients with prominent cerebral compression. During this dissection, the relatively thickened arachnoid mater provides a safe border 13).


A 67-year-old man presented with headache, dysphasia, and left-sided hemiparesis. Routine skull x-ray showed a huge calcification extending from the frontal to the parietal regions in the right side. CT and MRI scan revealed a huge ossified SDH covering the right hemisphere. Right frontoparietal craniotomy was performed and the ossified SDH was completely removed. Severe adhesion was noticed between the pia mater and the inner surface of the ossified mass. The subdural mass had ossified hard outer and inner rims and a soft central part. The postoperative course was uneventful and 3 months after the operation, the patient was neurologically intact. The authors report the successful treatment of a patient with a huge ossified SDH covering the right hemisphere. Careful dissection and total removal are needed in such symptomatic cases to avoid cortical injury and to improve results 14).


A 24-year-old man with a history of tonic-clonic convulsions since 7 months of age was admitted because of increasing frequency and duration of seizures. Computed tomography and magnetic resonance imaging demonstrated a fusiform extra-axial lesion just above the tentorium and adjacent to the cerebral falx. A calcified and ossified chronic subdural hematoma was noted and was almost completely removed by craniotomy. Better seizure control was achieved by the removal of the calcified chronic subdural hematoma. Calcified subdural hematoma, calcified epidural hematoma, calcified empyema, meningioma, calcified arachnoid cyst, and calcified convexity of the dura mater with acute epidural hematoma should be considered for the differential diagnosis of an extra-axial calcified lesion 15).


Turgut et al. reported the successful removal of an ossified crust-like chronic subdural hematoma (SDH) covering the hemisphere in a 16-year-old boy. In this article, the importance of the surgical approach is stressed, and the rarity of this condition in the neurosurgical literature is also outlined 16).


A case of ossified chronic subdural hematoma is presented in a 13-year-old male in whom the mass was surgically removed. His neurological deficits continued afterward but were less severe 17).

References

1) , 2) , 4)

Turgut M, Akhaddar A, Turgut AT. Calcified or Ossified Chronic Subdural Hematoma: A Systematic Review of 114 Cases Reported during Last Century with a Demonstrative Case Report. World Neurosurg. 2019 Nov 1. pii: S1878-8750(19)32791-3. doi: 10.1016/j.wneu.2019.10.153. [Epub ahead of print] Review. PubMed PMID: 31682989.
3) , 15)

Yan HJ, Lin KE, Lee ST, Tzaan WC. Calcified chronic subdural hematoma: case report. Changgeng Yi Xue Za Zhi. 1998 Dec;21(4):521-5. PubMed PMID: 10074745.
5)

Turgut M, Yay MÖ. A Rare Case of Ossified Chronic Subdural Hematoma Complicated with Tension Pneumocephalus. J Neurol Surg Rep. 2019 Oct;80(4):e44-e45. doi: 10.1055/s-0039-1694738. Epub 2019 Dec 31. PubMed PMID: 31908905; PubMed Central PMCID: PMC6938459.
6)

Liu X, Zhou J, Shen B, Sun D, Zhang Z, Li H, Zhang J. Ossified Chronic Subdural Hematoma and Subsequent Epstein-Barr Virus-Positive Large B-Cell Lymphoma: Case Report and Literature Review. World Neurosurg. 2019 Oct;130:165-169. doi: 10.1016/j.wneu.2019.07.011. Epub 2019 Jul 9. PubMed PMID: 31299306.
7)

Snopko P, Kolarovszki B, Opsenak R, Hanko M, Benco M. Chronic calcified subdural hematoma – case report of a rare diagnosis. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2019 Sep 26. doi: 10.5507/bp.2019.041. [Epub ahead of print] PubMed PMID: 31558846.
8)

Tian W, Meng X, Zou J. A Giant Ossified Chronic Subdural Hematoma. J Coll Physicians Surg Pak. 2019 Sep;29(9):905. doi: 10.29271/jcpsp.2019.09.905. PubMed PMID: 31455496.
9)

Fang J, Liu Y, Jiang X. Ossified Chronic Subdural Hematoma in Children: Case Report and Review of Literature. World Neurosurg. 2019 Jun;126:613-615. doi: 10.1016/j.wneu.2019.03.144. Epub 2019 Mar 27. PubMed PMID: 30926556.
10)

Siddiqui SA, Singh PK, Sawarkar D, Singh M, Sharma BS. Bilateral Ossified Chronic Subdural Hematoma Presenting as Diabetes Insipidus-Case Report and Literature Review. World Neurosurg. 2017 Feb;98:520-524. doi: 10.1016/j.wneu.2016.11.031. Epub 2016 Nov 17. Review. PubMed PMID: 27867130.
11)

Viozzi I, van Baarsen K, Grotenhuis A. Armored brain in a young girl with a syndromal hydrocephalus. Acta Neurochir (Wien). 2017 Jan;159(1):81-83. doi: 10.1007/s00701-016-2991-1. Epub 2016 Oct 25. PubMed PMID: 27778104; PubMed Central PMCID: PMC5177664.
12)

Turgut M, Samancoğlu H, Ozsunar Y, Erkuş M. Ossified chronic subdural hematoma. Cent Eur Neurosurg. 2010 Aug;71(3):146-8. doi: 10.1055/s-0030-1253346. Epub 2010 May 3. PubMed PMID: 20440672.
13)

Kaplan M, Akgün B, Seçer HI. Ossified chronic subdural hematoma with armored brain. Turk Neurosurg. 2008 Oct;18(4):420-4. PubMed PMID: 19107693.
14)

Moon HG, Shin HS, Kim TH, Hwang YS, Park SK. Ossified chronic subdural hematoma. Yonsei Med J. 2003 Oct 30;44(5):915-8. PubMed PMID: 14584111.
16)

Turgut M, Palaoğlu S, Sağlam S. Huge ossified crust-like subdural hematoma covering the hemisphere and causing acute signs of increased intracranial pressure. Childs Nerv Syst. 1997 Jul;13(7):415-7. PubMed PMID: 9298279.
17)

Iplikçioğlu AC, Akkaş O, Sungur R. Ossified chronic subdural hematoma: case report. J Trauma. 1991 Feb;31(2):272-5. PubMed PMID: 1994092.

Middle meningeal artery embolization for chronic subdural hematoma systematic reviews

Middle meningeal artery embolization for chronic subdural hematoma systematic reviews

Jumah et al. conducted a systematic review and meta-analysis (MA) in compliance with the PRISMA guidelines to evaluate the efficacy and safety of Middle meningeal artery embolization (MMAE) compared with conventional treatments for refractory or chronic subdural hematoma (cSDH). Databases were searched up to March 2019. Using a random-effects model, meta-analyses of proportions and risk differences were conducted recurrence, need for surgical rescue, and complications.

Eleven studies (177 patients) were included. The majority (116, 69%) were males with a weighted mean age of 71 + -19.5 years. A meta-analysis of proportions showed treatment failure to be 2.8%, the need for surgical rescue 2.7%, and embolization-related complications 1.2%. A meta-analysis of risk-difference between embolized and non-embolized patients showed a 26% (p < 0.001, 95% CI 21%-31%, I2 = 0) lower risk of hematoma recurrence in MMAE. Similarly, in the embolized group, the need for surgical rescue was 20% less (p < 0.001, 95% CI = 12%-27%, I2 = 12.4), and complications were 3.6% less (p = 0.008, 95% CI 1%-6%, I2 = 0) compared to conventional groups.

Although MMAE appears to be a promising treatment for refractory or cSDH, drawing definitive conclusions remains limited by the paucity of data and small sample sizes. Multicenter, randomized, prospective trials are needed to compare embolization to conventional treatments like watchful waiting, medical management, or surgical evacuation. More extensive research on MMAE could begin a new era in the minimally invasive management of cSDH 1).


The goal of a study was to review the evidence on MMAE in cSDH to assess its safety, feasibility, indications and efficacy. Court et al. performed a systematic review of the literature according to PRISMA guidelines using multiple electronic databases. This search yielded a total of 18 original articles from which data were extracted. A total of 190 patients underwent MMAE from which 81.3% were symptomatic cSDH. Over half (52.3%) of the described population were undergoing antithrombotic therapy. Most (83%) procedures used polyvinyl alcohol (PVA) particles and no complications were reported regarding the embolization procedures. Although the definition of resolution varied among authors, cSDH resolution was reported in 96.8% of cases. MMAE is a feasible technique for cSDH, but the current body of evidence does not yet support its use as a standard treatment. Further studies with a higher level of evidence are necessary before MMAE can be formally recommended 2).


Three double-arm studies comparing embolization and conventional surgery groups and 6 single-arm case series were identified and analyzed. Hematoma recurrence rate was significantly lower in the embolization group compared with conventional treatment group (2.1% vs. 27.7%; odds ratio = 0.087; 95% confidence interval, 0.026-0.292; P < 0.001; I2 = 0%); surgical complication rates were similar between groups (2.1% vs. 4.4%; odds ratio = 0.563; 95% confidence interval, 0.107-2.96; P = 0.497; I2 = 27.5%). Number of patients with modified Rankin Scale score >2 in the embolization (12.5%) versus conventional treatment (9.1%) group showed no statistical difference (P = 0.689). A composite hematoma recurrence rate of 3.6% was found after summing the 6 case series. Composite recurrence and complication rates in the embolization cohorts of the double-arm studies and the case series were lower than literature values for conventional surgical treatments.

MMA embolization is a promising treatment for chronic subdural hematoma. Future randomized clinical trials are needed 3).

References

1)

Jumah F, Osama M, Islim AI, Jumah A, Patra DP, Kosty J, Narayan V, Nanda A, Gupta G, Dossani RH. Efficacy and safety of middle meningeal artery embolization in the management of refractory or chronic subdural hematomas: a systematic review and meta-analysis. Acta Neurochir (Wien). 2020 Jan 4. doi: 10.1007/s00701-019-04161-3. [Epub ahead of print] Review. PubMed PMID: 31900658.
2)

Court J, Touchette CJ, Iorio-Morin C, Westwick HJ, Belzile F, Effendi K. Embolization of the Middle meningeal artery in chronic subdural hematoma – A systematic review. Clin Neurol Neurosurg. 2019 Aug 10;186:105464. doi: 10.1016/j.clineuro.2019.105464. [Epub ahead of print] Review. PubMed PMID: 31600604.
3)

Srivatsan A, Mohanty A, Nascimento FA, Hafeez MU, Srinivasan VM, Thomas A, Chen SR, Johnson JN, Kan P. Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: Meta-Analysis and Systematic Review. World Neurosurg. 2019 Feb;122:613-619. doi: 10.1016/j.wneu.2018.11.167. Epub 2018 Nov 24. PubMed PMID: 30481628.

Chronic subdural hematoma treatment

Chronic subdural hematoma treatment

A variety of clinical factors must be taken into account in the treatment of chronic subdural hematoma (cSDH), and the multifaceted treatment paradigms continue to evolve 1).

There is lack of uniformity about the treatment strategies, such as the role of burr holetwist drillcraniotomy, etc., in CSDH amongst various surgeons. There is also disagreement about the use of drainirrigation, and steroid 2) 3).

Surgery is usually the treatment of choice, but conservative treatment may be a good alternative in some situations.

see DECSA trial.

see Middle Meningeal Artery Embolization.

Chronic subdural hematoma surgery

Systematic reviews

Soleman et al., provide a systematic review of studies analysing the conservative treatment options and the natural history of cSDH. Of 231 articles screened, 35 were included in this systematic review. Studies evaluating the natural history and conservative treatment modalities of cSDH remain sparse and are predominantly of low level of evidence. The natural history of cSDH remains unclear and is analysed only in case reports or very small case series. “Wait and watch” or “wait and scan” management is indicated in patients with no or minor symptoms (Markwalder score 0-1). However, it seems that there are no clear clinical or radiological signs indicating whether the cSDH will resolve spontaneously or not (type C recommendation). In symptomatic patients who are not worsening or in a comatose state, oral steroid treatment might be an alternative to surgery (type C recommendation). Tranexamic acid proved effective in a small patient series (type C recommendation), but its risk of increasing thromboembolic events in patients treated with antithrombotic or anticoagulant medication is unclear. Angiotensin converting-enzyme inhibitors were evaluated only as adjuvant therapy to surgery, and their effect on the rate of recurrence remains debatable. Mannitol showed promising results in small retrospective series and might be a valid treatment modality (type C recommendation). However, the long treatment duration is a major drawback. Patients presenting without paresis can be treated with a platelet activating factor receptor antagonist (type C recommendation), since they seem to promote resolution of the haematoma, especially in patients with subdural hygromas or low-density haematomas on computed tomography. Lastly, atorvastatin seems to be a safe option for the conservative treatment of asymptomatic or mildly symptomatic cSDH patients (type C recommendation). In conclusion, the knowledge of the conservative treatment modalities for cSDH is sparse and based on small case series and low grade evidence. However, some treatment modalities seem promising even in symptomatic patients with large haematomas. Randomised controlled trials are currently underway, and will hopefully provide us with good evidence for or against the conservative treatment of cSDH 4).

Surveys

The aim of a study was to survey aspects of current practice in the UK and Ireland. A 1-page postal questionnaire addressing the treatment of primary (i.e. not recurrent) CSDH was sent to consultant SBNS members in March 2006. There were 112 responses from 215 questionnaires (52%). The preferred surgical technique was burr hole drainage (92%). Most surgeons prefer not to place a drain, with 27% never using one and 58% using drain only in one-quarter of cases or less. Only 11% of surgeons always place a drain, and only 30% place one in 75% of cases or more. The closed subdural-to-external drainage was most commonly used (91%) with closed subgaleal-to-external and subdural-to-peritoneal conduit used less often (3 and 4%, respectively). Only 5% of responders claimed to know the exact recurrence rate. The average perceived recurrence rate among the surgeons that never use drains and those who always use drains, was the same (both 11%). Most operations are performed by registrars (77%). Postoperative imaging is requested routinely by 32% of respondents and 57% of surgeons prescribe bed rest. Ninety four per cent surgeons employ conservative management in less than one-quarter of cases. Forty-two per cent of surgeons never prescribe steroids, 55% prescribe them to those managed conservatively. This survey demonstrates that there are diverse practices in the management of CSDH. This may be because of sufficiently persuasive evidence either does not exist or is not always taken into account. The current literature provides Class II and III evidence and there is a need for randomized studies to address the role of external drainage, steroids and postoperative bed rest 5).


Cenic et al. developed and administered a questionnaire to Canadian Neurosurgeons with questions relating to the management of chronic and subacute subdural hematoma. Our sampling frame included all neurosurgery members of the Canadian Neurosurgical Society.

Of 158 questionnaires, 120 were returned (response rate = 76%). The respondents were neurosurgeons with primarily adult clinical practices (108/120). Surgeons preferred one and two burr-hole craniostomy to craniotomy or twist-drill craniostomy as the procedure of choice for initial treatment of subdural hematoma (35.5% vs 49.5% vs 4.7% vs 9.3%, respectively). Craniotomy and two burr-holes were preferred for recurrent subdural hematomas (43.3% and 35.1%, respectively). Surgeons preferred irrigation of the subdural cavity (79.6%), use of a subdural drain (80.6%), and no use of anti-convulsants or corticosteroids (82.1% and 86.6%, respectively). We identified a lack of consensus with keeping patients supine following surgery and post-operative antibiotic use.

The survey has identified variations in practice patterns among Canadian Neurosurgeons with respect to treatment of subacute or chronic subdural hematoma (SDH). Our findings support the need for further prospective studies and clinical trials to resolve areas of discrepancies in clinical management and hence, standardize treatment regimens 6).

Glucocorticoids

Since glucocorticoids have been used for treatment of cSDH in 1962 their role is still discussed controversially in lack of evident data. On the basis of the ascertained inflammation cycle in cSDH dexamethasone will be an ideal substance for a short lasting, concomitant treatment protocol.

A study is designed as a double-blind randomized placebo-controlled trial 820 patients who are operated for cSDH and from the age of 25 years are included after obtaining informed consent. They are randomized for administration of dexamethasone (16-16-12-12-8-4 mg/d) or placebo (maltodextrin) during the first 48 hours after surgery. The type I error is 5% and the type II error is 20%. The primary endpoint is the reoperation within 12 weeks postoperative.

This study tests whether dexamethasone administered over 6 days is a safe and potent agent in relapse prevention for evacuated cSDH 7).

Chronic subdural hematoma seizure prophylaxis

Anticoagulation resumption after chronic subdural hematoma

References

1)

Sahyouni R, Goshtasbi K, Mahmoodi A, Tran DK, Chen JW. Chronic Subdural Hematoma: A Historical and Clinical Perspective. World Neurosurg. 2017 Dec;108:948-953. doi: 10.1016/j.wneu.2017.09.064. Epub 2017 Sep 19. Review. PubMed PMID: 28935548.
2) , 5)

Santarius T, Lawton R, Kirkpatrick PJ, Hutchinson PJ. The management of primary chronic subdural haematoma: a questionnaire survey of practice in the United Kingdom and the Republic of Ireland. Br J Neurosurg. 2008 Aug;22(4):529-34. doi: 10.1080/02688690802195381. PubMed PMID: 18686063.
3)

Cenic A, Bhandari M, Reddy K. Management of chronic subdural hematoma: a national survey and literature review. Can J Neurol Sci. 2005 Nov;32(4):501-6. PubMed PMID: 16408582.
4)

Soleman J, Noccera F, Mariani L. The conservative and pharmacological management of chronic subdural haematoma. Swiss Med Wkly. 2017 Jan 19;147:w14398. doi: smw.2017.14398. PubMed PMID: 28102879.
6)

Cenic A, Bhandari M, Reddy K. Management of chronic subdural hematoma: a national survey and literature review. Can J Neurol Sci. 2005 Nov;32(4):501-6. PubMed PMID: 16408582.
7)

Emich S, Richling B, McCoy MR, Al-Schameri RA, Ling F, Sun L, Wang Y, Hitzl W. The efficacy of dexamethasone on reduction in the reoperation rate of chronic subdural hematoma – the DRESH study: straightforward study protocol for a randomized controlled trial. Trials. 2014 Jan 6;15(1):6. doi: 10.1186/1745-6215-15-6. PubMed PMID: 24393328; PubMed Central PMCID: PMC3891985.
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