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|LETTER TO EDITOR
|Year : 2021 | Volume
| Issue : 5 | Page : 1430-1431
Chronic Psychosis Unveiling the Diagnosis of the Armored Brain
Prashant K Prasad1, Manjul Tripathi2, Amit Joshi3
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 Submission||14-Nov-2019|
|Date of Decision||19-Nov-2019|
|Date of Acceptance||10-Jul-2020|
|Date of Web Publication||30-Oct-2021|
Associate Professor, Department of Neurosurgery, Neurosurgery Office, 5th Floor, Nehru Hospital, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
|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
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., 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., 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. 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., 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.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]