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Table of Contents    
LETTER TO EDITOR
Year : 2021  |  Volume : 69  |  Issue : 5  |  Page : 1430-1431

Chronic Psychosis Unveiling the Diagnosis of the Armored Brain


1 Department of Neurosurgery, Command Hospital, Chandimandir, Panchkula, Haryana, India
2 Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Neurosurgery, Tanda Medical College, Himanchal Pradesh, India

Date of Submission14-Nov-2019
Date of Decision19-Nov-2019
Date of Acceptance10-Jul-2020
Date of Web Publication30-Oct-2021

Correspondence Address:
Manjul Tripathi
Associate Professor, Department of Neurosurgery, Neurosurgery Office, 5th Floor, Nehru Hospital, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.329615

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How to cite this article:
Prasad PK, Tripathi M, Joshi A. Chronic Psychosis Unveiling the Diagnosis of the Armored Brain. Neurol India 2021;69:1430-1

How to cite this URL:
Prasad PK, Tripathi M, Joshi A. Chronic Psychosis Unveiling the Diagnosis of the Armored Brain. Neurol India [serial online] 2021 [cited 2021 Nov 30];69:1430-1. Available from: https://www.neurologyindia.com/text.asp?2021/69/5/1430/329615


Sir,

Chronic calcified SDH is a rare but known entity estimated to represent 0.3-2.7% of all the chronic SDH. Undoubtedly, the treatment of choice is surgical evacuation yet controversy looms on time and extent of management of calcified chronic SDH.[1],[2] 50 years old male was brought to the psychiatry clinic with complaints of chronic bipolar illness. His radiological evaluation revealed a large extraaxial lesion on the left frontoparietal region causing significant mass effect [Figure 1]a,[Figure 1]b,[Figure 1]c,[Figure 1]d. Intra-operatively, there was well-defined encapsulated extraarachnoidal CSDH non-adhering to the brain parenchyma [Figure 2]a,[Figure 2]b,[Figure 2]c,[Figure 2]d. After initial improvement, he deteriorated and repeat scan revealed intracranial hematoma of 60cc in left cerebral hemisphere. We performed decompressive craniectomy with evacuation of hematoma but the patient did not improve and died on the fifth postoperative day.
Figure 1: (a), CT scan head; (b), MRI brain T1 weighted image; (c), CT angiogram; and (d), MRI brain showing calcified chronic subdural hematoma in left frontoparietal area with mass effect

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Figure 2: (a), Large chronic SDH adhered to the bone with well preserved membranes; (b), Separated chronic well formed SDH with compression on the underlying brain; (c), Remodelling of the overlying bone; and (d), Incised mass showing formed blood of different ages

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CSDH is generally a result of trauma though coagulopathy, chronic alcoholism, intracranial hypotension due to over drainage by VP shunt may be causative factors with presentation varying from incidental detection to altered sensorium, headache and focal neurological deficit.[2],[3] Development of calcification may be a result of vascular thrombosis and absorption and circulation in the subdural space with few authors suggesting a role of local factors and metabolic causes in calcification with the time duration of calcification varying from few months to years.[4] Removal of calcified CSDH may lead to improvement in symptoms though this is not universal. The compression is unlikely to be removed with drainage of the organized hematoma and careful dissection of the calcified collection from undersurface of dura and the underlying brain is essential for any improvement. The literature advocates surgical intervention only in cases with acute or progressive neurological deterioration [Figure 3]. The two most common complications are recurrent intracerebral hematoma (ICH) or recollection of the fluid.[4],[5] Our patient developed massive ICH in the postoperative period and this might be secondary to re-perfusion injury in this case. Surgical evacuation of this hematoma might have led to perfusion pressure breakthrough causing altered intracranial homeostasis and such cases might benefit from aggressive surgical management.
Figure 3: Surgical algorithm for the management of chronic calcified subdural hematoma

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In our patient, it could not be ascertained if the nonresponsive bipolar disorder is a manifestation of underlying calcified CSDH or an incidental finding. Specific MR sequences such as SWI/DWI help in showing perfusion deficits in the underlying brain parenchyma, and/or vascular proliferation of the capsule of the hematoma. At present, authors have no definite recommendation to prevent such a dreaded complication and the question whether to address this condition is going to be a Sophie's Choice.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kaplan M, Akgun B, Seçer HI. Ossified chronic subdural haematoma with armored brain. Turk Neurosurg 2008;4:420-4.  Back to cited text no. 1
    
2.
Mori K, Maeda M. Surgical treatment of chronic subdural hematoma in 500 consecutive cases: Clinical characteristics, surgical outcome, complications, and recurrence rate. Neurol Med Chir (Tokyo) 2001;41:371-81.  Back to cited text no. 2
    
3.
Nizamie SH, Nizamie A, Borde M, Sharma S. Mania following head injury: Case reports and neuropsychological findings. Acta Psychiatrica Scandinavica 1988;77:637-9.  Back to cited text no. 3
    
4.
Afra D. Ossification of subdural hematoma: Report of two cases. J Neurosurg 1961;18:393-7.  Back to cited text no. 4
    
5.
Jong-Soo P, Eun-LK S, Dong-Won K, Sang-Pyo K. Calcifiedchronic subdural haematoma associated with intracerebral haematoma. J Korean Neurosurg 2003;34:177-8.  Back to cited text no. 5
    


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