Surgical Excision of Double Skull

A Rare Entity of Ossified Subdural Hematoma in a Footballer

Sir,

Chronic subdural hematoma (CSDH) is a collection of blood between dura mater and arachnoid.[¹] CSDH is a well-known complication of brain trauma, but ossification or calcification of CSDH is rare. The ossified chronic subdural hematoma (SDH) accounts for 0.3%–2.7% of CSDH.[²] The clinical feature of ossified CSDH consists of headache, weakness, lack of alertness, gait disturbances, confusion, and loss of consciousness.[³] Each case of ossified CSDH should be managed surgically. Several authors’ analyses suggest that surgery cannot improve chronic symptoms and is recommended only when acute or progressive neurological deterioration occurs.[⁴⁵] CSDH is a well-known complication of brain trauma among elderly people and the use of blood-thinning agents.[⁶] The mechanism of calcified SDH is currently still unknown. However, previous studies concluded poor circulation in subdural space with intravascular thrombosis. The development of calcification of CSDH was hypothesized on the prolonged existence of hematoma and the subdural space with stagnant blood due to inadequate arterial supply and inadequate venous return.

A 39-year-old male, a footballer by profession, was admitted to the neurosurgical department with a history of chronic headache for 2 years, difficulty in walking and swaying toward the right side for 1 week, and acute-onset vomiting. He had no comorbidities. Neurological examination revealed right-sided hemiparesis with a motor strength of 3. Rest neurological, general examination and routine laboratory results were unremarkable.

Magnetic resonance imaging suggested CSDH with peripheral calcification in the left frontoparietal region measuring approximately 32 mm in thickness. Mass effect on ipsilateral lateral ventricle and contalateral midline shift of 5.8mm was seen with evidence of edema on left cerebral hemisphere. The patient underwent left frontotemporoparietal (FTP) craniotomy, revealing a thick dura with an underlying hard ossified bone-like structure. The dura was opened and excised all along the ossified bone-like structure. The ossified bone-like structure was removed en bloc meticulously while maintaining the integrity of the arachnoid and underlying brain parenchyma [Figure 1]. The perioperative period was uneventful, and on further follow-up during the visit, the patient was symptomatically free. His right hemiparesis showed improvement.

Figure 1: Inintraoperative images, (a) Left FTP craniotomy, exposing the dura with the mould of the underlying calcified chronic subdural hematoma’s capsule, (b) dissection of the inner surface of the dura from the underlying calcified capsule, (c) the inner membrane, which was not adherent to parenchymal surface, allowing for its complete removal without injuring the underlying brain, (d) the lack of brain reexpansion after complete removal of the hematoma, (e) the removed calcified hematoma

From this experience, it is clear that excision of ossified or calcified chronic SDH is practical and often results in good neurological outcomes.

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Conflicts of interest

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