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Ossified Chronic Subdural Hematoma in Children: Case Report and Review of Literature
Accepted Manuscript Ossified chronic subdural hematoma in children: a case report Jincheng Fang, Yun liu PII:
S1878-8750(19)30822-8
DOI:
https://doi.org/10.1016/j.wneu.2019.03.144
Reference:
WNEU 11871
To appear in:
World Neurosurgery
Received Date: 5 January 2019 Revised Date:
13 March 2019
Accepted Date: 14 March 2019
Please cite this article as: Fang J, liu Y, Ossified chronic subdural hematoma in children: a case report, World Neurosurgery (2019), doi: https://doi.org/10.1016/j.wneu.2019.03.144. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Ossified chronic subdural hematoma in children: a case report Jincheng Fang, Yun liu Department of Neurosurgery, Yijishan Hospital of Wannan
RI PT
Medical College, Wuhu, Anhui, China. Wannan Medical College, Wuhu, Anhui, China. Abstract:
SC
Chronic subdural hematoma (CSDH) is a frequently clinical
M AN U
common problem encountered in neurosurgery practice. Nevertheless, ossified chronic subdural hematoma is extremely rare, especially in children group. Here we report a case of ossified chronic subdural hematoma in a 7-year-old female
TE D
child, with a literature review. Because of its infrequency and variable clinical manifestaion, ossified chronic subdural hematoma should be considered and included in the
EP
differential diagnosis at the time when we encounter
AC C
intracranial placeholder. Keywords:
Ossified chronic subdural hematoma; children Introduction:
Chronic subdural hematoma (CSDH) is a frequently clinical common problem encountered in neurosurgery practice[1]. It’s usually thought of as a traumatic lesion in head injury.
ACCEPTED MANUSCRIPT
Nevertheless,
ossified
chronic
subdural
hematoma
are
extremely rare, especially in children group[2-4]. Although it’s can be diagnosed in any age group, but the incidence rises
RI PT
appreciably in the elderly population[5]. Almost no related articles report characteristic imaging of ossified chronic subdural hematoma in children up to now. In the rest of the
SC
article, we report a case of ossified chronic subdural hematoma
M AN U
in a 7-year-old female child, with a literature review. Case report:
Our department admitted a 7-year-old female patient who had epileptic seizures an hour after a head injury. The patient
TE D
denied that she had history of head trauma or epilepsy before. Neurological and physical examination was unremarkable. In addition,there were not any bleeding tendency, metabolic
EP
changes, endocrinological disorder or other abnormalities
AC C
according to the blood tests. Computed tomography (CT) multiplanar reconstruction images revealed the subdural with annular calcified in the left fronto-temporal lobe, and the central part of the lesion presented as a fluid density whereas the surrounding presented as an irregular high density (Figure 1). On magnetic resonance imaging (MRI), the lesion showed fluid signal intensity on T2-weighted images and an annular
ACCEPTED MANUSCRIPT
strengthening signal on contrast enhanced magnetic resonance imaging (Figure 2). During the left fronto-temporal craniotomy operation,after removing the bone and opening the dura mater,
RI PT
we could observe a giant ossified thick and hard capsule covering the convexity(Figure 3). It’s like an armor blocking the expansion of the brain. After excising the ossified capsule,the
SC
inner cerebral cortex was exposed. Moreover histopathological
M AN U
examination revealed a completely ossified bony structure and thicker ossification on the inside and outside margins of the hematoma (Figure 4). One week after surgery, review of head CT showed complete resection of the lesion, with good
Discussion:
TE D
recovery (Figure 5).
Chronic subdural hematoma (CSDH) is a frequently clinical
EP
common problem encountered in neurosurgery practice[1].
AC C
McKissock et al reported this disease for the first time after follow-up[6]. It’s a complication of head trauma,which usually happens after a minor head injury. Headache is the most obvious symptom of chronic subdural hematoma, followed by confusion of thinking, lethargy, memory impairment and epilepsy.[6] However, the mechanism of pathogenesis is still unclear and there are no absolute opinions regarding the
ACCEPTED MANUSCRIPT
clinical diagnosis and treatment. Some studies have suggested that vascular malformations, coagulopathy, chronic alcoholism, intracranial hypotension and primary or metastatic tumors may
RI PT
play great roles in the etiology of CSDH[7]. The next stage in the development of chronic subdural hematoma is calcification
after at least 6 months[8]. And after a few years calcification
SC
develops into ossification. The pathogenesis of Ossified chronic
M AN U
subdural hematoma (OSDH) is also not clearly understood. Ossified chronic subdural hematoma makes up 0.8% to 10% of the total chronic subdural hematoma
according to the statistics[9]. Compared to other types of
TE D
chronic subdural hematoma, ossified chronic subdural hematoma is more common in children and young adults than in older adults[10]. In the present case, the patient is a
EP
7-year-old female, presented with epileptic seizures. The
AC C
parents denied that the patient had suffered any trauma before, but considering of the ossified chronic subdural hematoma, we thought the child might have minor trauma before symptoms appeared. Since young people are more susceptible to increased intracranial pressure, headaches are more easily observed.But in this case, the children did not complain of headaches. Instead, seizures were identified as the first
ACCEPTED MANUSCRIPT
symptoms,which indirectly reflected the particularity of the case. As for patients who are old or asymptomatic,because of the risk of cortical injury, ossified subdural hematoma is usually
RI PT
treated conservatively. But for young or symptomatic patients, surgical treatment is reported to be necessary [11, 12].
Therefore we suggest the complete resection for severe
SC
symptomatic patients like the present case. Because of it’s
M AN U
infrequency and possibly variable presentation, ossified chronic subdural hematoma should be considered and included in the differential diagnosis when we encounter intracranial placeholder.
TE D
References:
1. Mori, K. and M. Maeda, Surgical treatment of chronic subdural hematoma in 500 consecutive cases: clinical
EP
characteristics, surgical outcome, complications, and recurrence
AC C
rate. Neurol Med Chir (Tokyo), 2001. 41(8): p. 371-81. 2.Dinc, C., et al., Bilateral calsified chronic subdural hematoma: Case report. Turk Norosirurji Dergisi, 2006. 16: p. 126-129. 3. Kaplan, M., B. Akgun and H.I. Secer, Ossified chronic subdural hematoma with armored brain. Turk Neurosurg, 2008. 18(4): p. 420-4. 4. Per, H., et al., Calcified chronic subdural hematoma
ACCEPTED MANUSCRIPT
mimicking calvarial mass: a case report. Brain Dev, 2006. 28(9): p. 607-9. 5. Chen, J.C. and M.L. Levy, Causes, epidemiology, and risk
RI PT
factors of chronic subdural hematoma. Neurosurg Clin N Am, 2000. 11(3): p. 399-406.
6. McKissock, W., A. Richardson and W. Bloom, Subdural
SC
hematomas: a review of 389 cases. Lancet, 1960. 275: p.
M AN U
1365–69.
7. Cattalani, A., et al., Transcranial color-coded duplex sonography for evaluation of midline-shift after chronic-subdural hematoma evacuation (TEMASE): A
101-107.
TE D
prospective study. Clin Neurol Neurosurg, 2017. 162: p.
8. Turgut, M., S. Palaoglu and S. Saglam, Huge ossified
EP
crust-like subdural hematoma covering the hemisphere and
AC C
causing acute signs of increased intracranial pressure. Childs Nerv Syst, 1997. 13(7): p. 415-7. 9. Park, J., et al., Calsified chronic subdural hematoma associated with intracerebral hematoma: Case report. J Korean Neurosurg Soc, 2003(34): p. 177-178. 10. Ide, M., et al., Asymptomatic calcified chronic subdural hematoma--report of three cases. Neurol Med Chir (Tokyo),
ACCEPTED MANUSCRIPT
1993. 33(8): p. 559-63. 11. Moon, H.G., et al., Ossified chronic subdural hematoma. Yonsei Med J, 2003. 44(5): p. 915-8.
RI PT
12. Per, H., et al., Calcified chronic subdural hematoma mimicking calvarial mass: a case report. Brain Dev, 2006. 28(9):
TE D
M AN U
SC
p. 607-9.
Figure 1. CT multiplanar reconstruction images revealed a
EP
subdural with annular calcified in the left fronto-temporal lobe, and the central part of the lesion presented as a fluid density
AC C
whereas the surrounding presented as an irregular high density.
SC
RI PT
ACCEPTED MANUSCRIPT
Figure 2. On magnetic resonance imaging (MRI), the lesion
M AN U
showed fluid signal intensity on T2-weighted images and an annular strengthening signal on contrast enhanced magnetic
AC C
EP
TE D
resonance imaging.
Figure 3. After the bone was lifted and the dura mater was opened, a giant ossified thick and hard capsule covering the convexity was observed.
RI PT
ACCEPTED MANUSCRIPT
SC
Figure 4. Histopathologic examination revealed a completely
M AN U
ossified bony structure and thicker ossification on the inside
AC C
EP
TE D
and outside margins of the hematoma.
Figure 5. One week after surgery, review of head CT showed complete resection of the lesion, with good recovery.
ACCEPTED MANUSCRIPT
CSDH CT
Computed tomography magnetic resonance imaging
AC C
EP
TE D
M AN U
SC
RI PT
MRI
Chronic subdural hematoma
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
Conflict of interest statement We declare that we have no financial and personal relationships with other people or organizations that can inappropriately influence our work, there is no professional or other personal interest of any nature or kind in any product, service and/or company that could be construed as influencing the position presented in, or the review of, the manuscript entitled, “Ossified chronic subdural hematoma in children a case report and review of the literature”
S1878-8750(19)30822-8
DOI:
https://doi.org/10.1016/j.wneu.2019.03.144
Reference:
WNEU 11871
To appear in:
World Neurosurgery
Received Date: 5 January 2019 Revised Date:
13 March 2019
Accepted Date: 14 March 2019
Please cite this article as: Fang J, liu Y, Ossified chronic subdural hematoma in children: a case report, World Neurosurgery (2019), doi: https://doi.org/10.1016/j.wneu.2019.03.144. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Ossified chronic subdural hematoma in children: a case report Jincheng Fang, Yun liu Department of Neurosurgery, Yijishan Hospital of Wannan
RI PT
Medical College, Wuhu, Anhui, China. Wannan Medical College, Wuhu, Anhui, China. Abstract:
SC
Chronic subdural hematoma (CSDH) is a frequently clinical
M AN U
common problem encountered in neurosurgery practice. Nevertheless, ossified chronic subdural hematoma is extremely rare, especially in children group. Here we report a case of ossified chronic subdural hematoma in a 7-year-old female
TE D
child, with a literature review. Because of its infrequency and variable clinical manifestaion, ossified chronic subdural hematoma should be considered and included in the
EP
differential diagnosis at the time when we encounter
AC C
intracranial placeholder. Keywords:
Ossified chronic subdural hematoma; children Introduction:
Chronic subdural hematoma (CSDH) is a frequently clinical common problem encountered in neurosurgery practice[1]. It’s usually thought of as a traumatic lesion in head injury.
ACCEPTED MANUSCRIPT
Nevertheless,
ossified
chronic
subdural
hematoma
are
extremely rare, especially in children group[2-4]. Although it’s can be diagnosed in any age group, but the incidence rises
RI PT
appreciably in the elderly population[5]. Almost no related articles report characteristic imaging of ossified chronic subdural hematoma in children up to now. In the rest of the
SC
article, we report a case of ossified chronic subdural hematoma
M AN U
in a 7-year-old female child, with a literature review. Case report:
Our department admitted a 7-year-old female patient who had epileptic seizures an hour after a head injury. The patient
TE D
denied that she had history of head trauma or epilepsy before. Neurological and physical examination was unremarkable. In addition,there were not any bleeding tendency, metabolic
EP
changes, endocrinological disorder or other abnormalities
AC C
according to the blood tests. Computed tomography (CT) multiplanar reconstruction images revealed the subdural with annular calcified in the left fronto-temporal lobe, and the central part of the lesion presented as a fluid density whereas the surrounding presented as an irregular high density (Figure 1). On magnetic resonance imaging (MRI), the lesion showed fluid signal intensity on T2-weighted images and an annular
ACCEPTED MANUSCRIPT
strengthening signal on contrast enhanced magnetic resonance imaging (Figure 2). During the left fronto-temporal craniotomy operation,after removing the bone and opening the dura mater,
RI PT
we could observe a giant ossified thick and hard capsule covering the convexity(Figure 3). It’s like an armor blocking the expansion of the brain. After excising the ossified capsule,the
SC
inner cerebral cortex was exposed. Moreover histopathological
M AN U
examination revealed a completely ossified bony structure and thicker ossification on the inside and outside margins of the hematoma (Figure 4). One week after surgery, review of head CT showed complete resection of the lesion, with good
Discussion:
TE D
recovery (Figure 5).
Chronic subdural hematoma (CSDH) is a frequently clinical
EP
common problem encountered in neurosurgery practice[1].
AC C
McKissock et al reported this disease for the first time after follow-up[6]. It’s a complication of head trauma,which usually happens after a minor head injury. Headache is the most obvious symptom of chronic subdural hematoma, followed by confusion of thinking, lethargy, memory impairment and epilepsy.[6] However, the mechanism of pathogenesis is still unclear and there are no absolute opinions regarding the
ACCEPTED MANUSCRIPT
clinical diagnosis and treatment. Some studies have suggested that vascular malformations, coagulopathy, chronic alcoholism, intracranial hypotension and primary or metastatic tumors may
RI PT
play great roles in the etiology of CSDH[7]. The next stage in the development of chronic subdural hematoma is calcification
after at least 6 months[8]. And after a few years calcification
SC
develops into ossification. The pathogenesis of Ossified chronic
M AN U
subdural hematoma (OSDH) is also not clearly understood. Ossified chronic subdural hematoma makes up 0.8% to 10% of the total chronic subdural hematoma
according to the statistics[9]. Compared to other types of
TE D
chronic subdural hematoma, ossified chronic subdural hematoma is more common in children and young adults than in older adults[10]. In the present case, the patient is a
EP
7-year-old female, presented with epileptic seizures. The
AC C
parents denied that the patient had suffered any trauma before, but considering of the ossified chronic subdural hematoma, we thought the child might have minor trauma before symptoms appeared. Since young people are more susceptible to increased intracranial pressure, headaches are more easily observed.But in this case, the children did not complain of headaches. Instead, seizures were identified as the first
ACCEPTED MANUSCRIPT
symptoms,which indirectly reflected the particularity of the case. As for patients who are old or asymptomatic,because of the risk of cortical injury, ossified subdural hematoma is usually
RI PT
treated conservatively. But for young or symptomatic patients, surgical treatment is reported to be necessary [11, 12].
Therefore we suggest the complete resection for severe
SC
symptomatic patients like the present case. Because of it’s
M AN U
infrequency and possibly variable presentation, ossified chronic subdural hematoma should be considered and included in the differential diagnosis when we encounter intracranial placeholder.
TE D
References:
1. Mori, K. and M. Maeda, Surgical treatment of chronic subdural hematoma in 500 consecutive cases: clinical
EP
characteristics, surgical outcome, complications, and recurrence
AC C
rate. Neurol Med Chir (Tokyo), 2001. 41(8): p. 371-81. 2.Dinc, C., et al., Bilateral calsified chronic subdural hematoma: Case report. Turk Norosirurji Dergisi, 2006. 16: p. 126-129. 3. Kaplan, M., B. Akgun and H.I. Secer, Ossified chronic subdural hematoma with armored brain. Turk Neurosurg, 2008. 18(4): p. 420-4. 4. Per, H., et al., Calcified chronic subdural hematoma
ACCEPTED MANUSCRIPT
mimicking calvarial mass: a case report. Brain Dev, 2006. 28(9): p. 607-9. 5. Chen, J.C. and M.L. Levy, Causes, epidemiology, and risk
RI PT
factors of chronic subdural hematoma. Neurosurg Clin N Am, 2000. 11(3): p. 399-406.
6. McKissock, W., A. Richardson and W. Bloom, Subdural
SC
hematomas: a review of 389 cases. Lancet, 1960. 275: p.
M AN U
1365–69.
7. Cattalani, A., et al., Transcranial color-coded duplex sonography for evaluation of midline-shift after chronic-subdural hematoma evacuation (TEMASE): A
101-107.
TE D
prospective study. Clin Neurol Neurosurg, 2017. 162: p.
8. Turgut, M., S. Palaoglu and S. Saglam, Huge ossified
EP
crust-like subdural hematoma covering the hemisphere and
AC C
causing acute signs of increased intracranial pressure. Childs Nerv Syst, 1997. 13(7): p. 415-7. 9. Park, J., et al., Calsified chronic subdural hematoma associated with intracerebral hematoma: Case report. J Korean Neurosurg Soc, 2003(34): p. 177-178. 10. Ide, M., et al., Asymptomatic calcified chronic subdural hematoma--report of three cases. Neurol Med Chir (Tokyo),
ACCEPTED MANUSCRIPT
1993. 33(8): p. 559-63. 11. Moon, H.G., et al., Ossified chronic subdural hematoma. Yonsei Med J, 2003. 44(5): p. 915-8.
RI PT
12. Per, H., et al., Calcified chronic subdural hematoma mimicking calvarial mass: a case report. Brain Dev, 2006. 28(9):
TE D
M AN U
SC
p. 607-9.
Figure 1. CT multiplanar reconstruction images revealed a
EP
subdural with annular calcified in the left fronto-temporal lobe, and the central part of the lesion presented as a fluid density
AC C
whereas the surrounding presented as an irregular high density.
SC
RI PT
ACCEPTED MANUSCRIPT
Figure 2. On magnetic resonance imaging (MRI), the lesion
M AN U
showed fluid signal intensity on T2-weighted images and an annular strengthening signal on contrast enhanced magnetic
AC C
EP
TE D
resonance imaging.
Figure 3. After the bone was lifted and the dura mater was opened, a giant ossified thick and hard capsule covering the convexity was observed.
RI PT
ACCEPTED MANUSCRIPT
SC
Figure 4. Histopathologic examination revealed a completely
M AN U
ossified bony structure and thicker ossification on the inside
AC C
EP
TE D
and outside margins of the hematoma.
Figure 5. One week after surgery, review of head CT showed complete resection of the lesion, with good recovery.
ACCEPTED MANUSCRIPT
CSDH CT
Computed tomography magnetic resonance imaging
AC C
EP
TE D
M AN U
SC
RI PT
MRI
Chronic subdural hematoma
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
Conflict of interest statement We declare that we have no financial and personal relationships with other people or organizations that can inappropriately influence our work, there is no professional or other personal interest of any nature or kind in any product, service and/or company that could be construed as influencing the position presented in, or the review of, the manuscript entitled, “Ossified chronic subdural hematoma in children a case report and review of the literature”