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|LETTER TO EDITOR
|Year : 2013 | Volume
| Issue : 2 | Page : 195-197
Same side double chronic calcified epidural hematoma: Case report and review of literature
Pankaj Dawar, Manoj Phalak, Sumit Sinha, Bhawani S Sharma
Department of Neurosurgery, All India Institute of Medical Sciences, Associated Jai Prakash Narayan Apex Trauma Centre, New Delhi, India
|Date of Submission||21-Jan-2013|
|Date of Decision||28-Jan-2012|
|Date of Acceptance||29-Mar-2013|
|Date of Web Publication||29-Apr-2013|
Department of Neurosurgery, All India Institute of Medical Sciences, Associated Jai Prakash Narayan Apex Trauma Centre, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Dawar P, Phalak M, Sinha S, Sharma BS. Same side double chronic calcified epidural hematoma: Case report and review of literature. Neurol India 2013;61:195-7
Ipsilateral occurrence of more than one extradural hematoma (EDH) is rare  and calcification or ossification of EDH is further uncommon. ,, We describe one such rare clinical entity.
An 18-year-old boy who had a fall from the second floor and sustained a head injury 20 days prior was managed conservatively for EDH as the clinical condition was stable at some other facility. His condition had deteriorated progressively within the 6 h before referral to our facility. At admission, he was in altered mental status and had features of elevated intracranial pressure. Right pupil was dilated and non-reacting. Routine laboratory tests were normal. Non-contrast brain computed tomography (CT) carried out at the other facility [Figure 1] and the repeat CT carried out at our facility [Figure 2] revealed two EDHs on right frontal and parietal regions. The CT carried out at our facility [Figure 2] revealed a thick hyperdense layer along the inner border of the EDH not present on initial scan. These findings were interpreted as atypical calcified EDHs. An emergent large right fronto-temporo-parietal craniotomy covering both the EDH was done. During the surgery, after evacuating the EDH, a hard, osseous layer of approximately 3 mm thickness was encountered densely adherent to the entire dura mater with no clear demarcation between the dura mater and osseous layer. The entire osseous layer was removed by careful dissection away from the dura mater under an operating microscope. The post-operative course was uneventful, and a post-operative CT demonstrated total removal of the hematoma with the ossified layer [Figure 3]. The patient was discharged on the seventh post-operative day with improved left-side motor strength.
|Figure 1: Initial NCCT head showing double epidural hematoma on the same side, right frontal and right parietal region|
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|Figure 2: NCCT head done 3 weeks later showing lack of resolution of hematoma with thick hyperdense layer on dural side suggestive of calcification|
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|Figure 3: NCCT head carried out in the post-operative period showing complete evacuation of hematoma and brain expansion and no empty epidural dead space|
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Double EDH may be unilateral or bilateral and account for 2-25% of all EDHs.  Most often double EDH occur bilaterally due to the coup and contrecoup injuries, only rarely two or more EDH occur on one side.  In our case, there was double EDH as a result of coup injury on right frontal aspect with venous bleeding from superior sagittal sinus and a contrecoup injury at right fronto-parietal region with bleeding from the middle-meningeal-artery or vein.
Early occurrence of calcification and ossification in traumatic EDH is extremely rare. In the pediatric cases reported by Kawata et al. ossification of EDH occurred 4 months and 12 days after head injury.  Erdogan et al. reported an 8-year-old boy in whom calcification and ossification of epidural hematoma occurred within 10 days of injury.  Chang et al. reported occurrence of ossification of EDH 73 days after head injury and emphasized the importance of surgery even when patient condition is stable.  The occurrence of EDH in the pediatric age group is unusual because the dura mater is relatively firmly adhered to the inner table and suture line. In the children, EDH is of venous origin and it takes longer time for the blood to accumulate in adequate volume to cause significant mass effect. Probably this could be the reason why most children and infants with epidural hematoma do not deteriorate rapidly and present with the chronic form. 
The precise mechanism of calcification and ossification is uncertain. One of the hypothesis postulates that damage to highly vascular tissues such as bone and dura incites and initiates a tissue response, including inflammation, repair, and remodeling. This natural sequence of healing is more prompt in children than in adults. In our patient, no obvious pathology that could predispose the patient for early calcification or ossification was detected. The early ossification in this child could be due to the occurrence of disproportionate repair of tissue following acute injury.  Rapid ossification may prevent absorption or resolution of the hematoma and thus, can cause neurological deficits secondary to mass effect.  Furthermore, expansion of an EDH may also result from repeated bleeding from the inner table of the skull  or due to oozing from the dural surface veins.
The patient had been conservatively followed-up for 20 days at other facility as he was clinically stable. Repeat CT done when the neurological status of the patient deteriorated, revealed non-resolution of EDHs and thick hyperdense layer on the dural side. Despite the ossified layer, which in itself did not cause any mass effect, we removed all of it, thus, allowing for brain and dural expansion, preventing epidural dead space formation, and possible blood re-accumulation.
| » References|| |
|1.||Huda MF, Mohanty S, Sharma V, Tiwari Y, Choudhary A, Singh VP. Double extradural hematoma: An analysis of 46 cases. Neurol India 2004;52:450-2. |
|2.||Kawata Y, Kunimoto M, Sako K, Hashimoto M, Suzuki N, Ohgami S, et al. Ossified epidural hematomas: Report of two cases. No Shinkei Geka 1994;22:51-4. |
|3.||Erdogan B, Sen O, Bal N, Cekinmez M, Altinors N. Rapidly calcifying and ossifying epidural hematoma. Pediatr Neurosurg 2003;39:208-11. |
|4.||Chang JH, Choi JY, Chang JW, Park YG, Kim TS, Chung SS. Chronic epidural hematoma with rapid ossification. Childs Nerv Syst 2002;18:712-6. |
|5.||Kaye EM, Cass PR, Dooling E, Rosman NP. Chronic epidural hematomas in childhood: Increased recognition and non-surgical management. Pediatr Neurol 1985;1:255-9. |
|6.||Raimondi AJ. Trauma pediatric neurosurgery. Newyork: springer; 1987. p. 343-77. |
[Figure 1], [Figure 2], [Figure 3]