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Neuroradiology Case of the Week

Case 519

October 2010

Scott Cassar, MD and P-L Westesson, MD, PhD, DDS

Clinical Presentation: Patient is a 44-year-old female with right facial droop and clinical suspicion of an acute stroke.

Imaging Findings: No evidence of acute infarct. Stable ventriculomegaly and frontal encephalomalacia status post bilateral craniotomies. Incidentally noted however are multiple subdural abnormalities described below.

Figure 1A : MR brain, sagittal T1-weighted image; hyperintense subdural irregularity with a hypointense rim.

Figure 1B: MR brain, axial T1-weighted image; multiple hyperintense subdural irregularities with hypointense margins.

 Figure 1C: MR brain, axial T2-FLAIR; hyperintense subdural irregularities with hypointense margins.

Figure 1D: MR brain, axial GRE; these lesions show decreased signal intensity.

 Figure 1E: MR brain, axial T2-weighted image; hyperintense subdural irregularities with hypointense margins.

Figure 2: CT brain, axial slice in bone windows; bilateral subdural calcifications.

Figure 3: Skull radiograph, lateral view; bilateral subdural calcifications in patient status post bilateral craniotomies for subdural hemorrhages.

Diagnosis: Bilateral subdural calcifications

Discussion: Calcification and ossification of chronic subdural hematomas is a rare entity which occurs in 0.8 to 10% of subdural hematomas. They have been reported with arrested hydrocephalus as a late sequalae of shunt operation in infancy. The typical presentation is in children or young adults and is seizure, mental retardation, growth retardation, or headache. Calcified or ossified subdural hematomas are less common in adults where they may present asymptomatically or with milder symptoms. Treatment is surgical where the calcifications are painstakingly removed. This is reserved for young patients or for those with progressive neurological deficits. The patient in this case did not have a stroke but had a seizure which resulted in her symptoms. She had hydrocephalus as a newborn with shunt complications during childhood. A decade ago, she had undergone bilateral craniectomies for attempted removal of her calcified subdural hematomas with limited success due to fusion to the cortex.

References:

  1. Park JS, Son EI, Kim DW, Kim SP. Calcified chronic subdural hematoma associated with intracerebral hematoma. J Korean Neurosurg Soc. 2003 Aug; 34(2):177-178.
  2. Ide M, Jimbo M, Yamamoto M, Umebara Y, Hagiwara S. Asymptomatic calcified chronic subdural hematoma – report of three cases. Neurol Med Chir (Tokyo) 1993 Aug; 33(8): 559-63 PMID: 7692329 [PubMed]
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