Surgical Excision of Double Skull: A Rare Entity of Ossified Subdural Hematoma in a Footballer : Journal of Emergencies, Trauma, and Shock

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Surgical Excision of Double Skull

A Rare Entity of Ossified Subdural Hematoma in a Footballer

Sharma, Rahul; Katkar, Anand; Bhanage, Ashok; Reddy, G. Prem Kumar

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Journal of Emergencies, Trauma, and Shock 15(4):p 191-192, Oct–Dec 2022. | DOI: 10.4103/jets.jets_58_22
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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.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.


1. Per H, Gümüş H, Tucer B, Akgün H, Kurtsoy A, Kumandaş S Calcified chronic subdural hematoma mimicking calvarial mass:A case report. Brain Dev 2006;28:607–9.
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.
3. Pappamikail L, Rato R, Novais G, Bernardo E Chronic calcified subdural hematoma:Case report and review of the literature. Surg Neurol Int 2013;4:21
4. Oda S, Shimoda M, Hoshikawa K, Shiramizu H, Matsumae M Organized chronic subdural haematoma with a thick calcified inner membrane successfully treated by surgery:A case report. Tokai J Exp Clin Med 2010;35:85–8.
5. Yan HJ, Lin KE, Lee ST, Tzaan WC Calcifified chronic subdural hematoma:case report. Changgeng Yi Xue Za Zhi 1998;21:521–5.
6. Yadav YR, Parihar V, Namdev H, Bajaj J Chronic subdural hematoma. Asian J Neurosurg 2016;11:330–42.
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