Letters to Editor

Table 1: Metastatic intraventricular melanoma: Literature review

Sex, Location age Das Gupta 1964[1] Gaab 1999[2] Escott 2001[3]

Khoshyomn 2002[4]

Cipri 2009[5]

Symptoms

Primary tumor

Time after Other locations primary years

Treatment

Outcome

Choroid plexus M, 62 3rd ventricle, midbrain F, 31 Lateral ventricles M, 32 Left ventricle, choroid plexus M, 73 Multiple nodules of lateral, third, fourth ventricles

Drowsiness, confusion

M, 22 Septum pellucidum

Intermittent Unknown headache, vomiting, disequilibrium

Present case F, 60

Left lateral ventricle

Neuroendoscopic biopsy, 5 days, died ETV Right thigh

2

Headaches Headache, nausea, vomiting

Headache, vomiting, confusion

Lung, liver Right shoulder with negative axillary node

Left knee

36

10

Gamma knife

No

Neuroendoscopic biopsy of lateral ventricle lesions, radiotherapy, chemotherapy (methotrexate, cytosine arabinoside) Left inguinal, Neuroendoscopic biopsy, bilateral pellucidostomy, VP‑shunt, suprarenal, left stereotactic radiosurgery, bronchopulmonary chemotherapy (TMZ, parailar thalidomide) for systemic locations No Surgery, chemotherapy, 8 months, no radiotherapy recurrence

ETV ‑ Endoscopic third‑ventriculostomy, TMZ ‑ Temozolomide, VP‑shunt ‑ Ventriculo‑peritoneal shunt

have a preferential way for local invasion along the ependymal layer. This can explain the fluid collection between the two leaves of the septum pellucidum in our patient.

Alberto Feletti, Salima Magrini, Renzo Manara1, Enrico Orvieto2, Giacomo Pavesi Departments of Neurosurgery, 1Neuroradiology, 2Pathology, University Hospital of Padova, Padova, Italy E‑mail: [email protected]

References 1.

DasGupta T, Brasfield R. Metastatic melanoma. A clinicopathological study. Cancer 1964;17:1323‑39. 2. Gaab MR, Schroeder HW. Neuroendoscopic approach to intraventricular lesions. Neurosurg Focus 1999;6:e5. 3. Escott EJ. A variety of appearances of malignant melanoma in the head: A review. Radiographics 2001;21:625‑39. 4. Khoshyomn S, Braff SP, McKenzie MA, Florman JE, Pendlebury WW, Penar PL. Metastatic intraventricular melanoma. Case illustration. J Neurosurg 2002;97:726. 5. Cipri S, Mannino R, Cafarelli F. Metastatic melanoma of the septum pellucidum mimicking a colloidal cyst of the third ventricle. A novel case. J Neurosurg Sci 2009;53:125‑9. 6. Beatty RA. Malignant melanoma of the choroid plexus epithelium. Case report. J Neurosurg 1972;36:344‑7. 7. Shuangshoti S, Paisuntornsook P, Netsky MG. Melanosis of the choroid plexua. Neurology 1976;26:656‑8. 8. Lana‑Peixoto MA, Lagos J, Silbert SW. Primary pigmented carcinoma of the choroid plexus. A light and electron microscopic study. J Neurosurg 1977;47:442‑50. 9. Arbelaez A, Castillo M, Armao DM. Imaging features of intraventricular melanoma. AJNR Am J Neuroradiol 1999;20:691‑3. 548

Access this article online Quick Response Code:

Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.121949

Submission: 11‑08‑2013 Review completed: 31‑08‑2013 Accepted: 13‑10‑2013

Armored brain‑Massive bilateral calcified chronic subdural hematoma in a patient with ventriculoperotoneal shunt Sir, Calcification in chronic subdural hematoma  (CSDH) is uncommon and occurs in about 0.3%-2.7% cases.[1] This complication has rarely been reported in patients with CSDH following ventriculoperitoneal shunt for hydrocephalus. A 24‑year‑old male presented with progressive bilateral vision loss and polyuria since 2001. Neurology India | Sep-Oct 2013 | Vol 61 | Issue 5

Letters to Editor

a

b

c

d Figure 1: (a, b) Non contrast CT head done in 2007 revealing left frontotemporal calcified subdural hematoma with mass effect with minimal collection on right side, (c, d) Non contrast CT head done in 2012 revealing bilateral frontotemporal calcified subdural hematoma (left > right) with right parietal shunt in situ

a

Investigation at other facility showed visual acuity of 6/9 in both eyes and imaging revealed communicating hydrocephalous for which he underwent right parietal ventriculoperitoneal shunt in 2004. This was followed by improvement in both vision and polyuria. He was doing well till 2008, when he again started having polyuria and painless progressive visual diminution. He presented to us in 2012 with these complaints, and the visual acuity was perception of hand movements close to face with bilateral secondary optic atrophy. Noncontrast brain computed tomography (CT) revealed bilateral frontoparietal calcified chronic subdural hematoma and right parietal shunt in situ [Figures 1 and 2]. Calcified CSDH is also described as armored brain or Matrioska head. [1] Taha [2] could find only 18 such cases in the literature till 2012. The exact mechanism of calcifications is still an enigma. Microscopic calcium deposits within the membranes of the hematoma may proceed to extensive calcification and even ossifications in some cases. An underlying metabolic abnormality and poor circulation with delayed resorption of the hematoma fluid are other putative factors. These patients may be asymptomatic and when symptomatic present with signs of elevated intracranial pressure, seizures, and mental retardation. Symptoms may develop many years after shunt surgery.[3] CT or magnetic resonance imaging confirms diagnosis and can also differentiate it from other calcified extraaxial lesions like calcified epidural hematoma, meningioma, and malignant tumors.[4] The management of calcified chronic subdural hematoma is a matter of controversy and it is recommended that surgical intervention should be limited to patients who have progressive neurological deficits or evidence of increased intracranial pressure.

b

Kanwaljeet Garg, Pankaj Kumar Singh, Raghav Singla, P. Sarat Chandra, Manmohanjit Singh, Guru Dutt Satyarthhe, Hitesh Kumar Gurjar, Bhawani Shankar Sharma Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi‑110 029, India. E‑mail: [email protected]

References c Figure 2: (a) T1WI axial section showing hyperintense left frontotemporal extraaxial collection and hypointense right frontal collection, (b) T2WI axial section showing left frontotemporal extraaxial hypointense collection compressing the brain parenchyma, and (c) T2WI coronal section showing bilateral extraaxial hypointense collection compressing the brain parenchyma (left > right)

Neurology India | Sep-Oct 2013 | Vol 61 | Issue 5

1.

Sharma RR, Mahapatra A, Pawar SJ, Sousa J, Athale SD. Symptomatic calcified subdural hematomas. Pediatr Neurosurg 1999;31:150‑4. 2. Taha MM. Armored brain in patients with hydrocephalus after shunt surgery: Review of the literatures. Turk Neurosurg 2012;22:407‑10. 3. Amr R, Maraqa L, Choudry Q. ‘Armoured brain’. A case report of calcified chronic subdural hematoma. Pediatr Neurosurg 2008;44:88‑9. 549

Letters to Editor

4.

Kaspera W, Bierzynska‑Macyszyn G, Majchrzak H. Chronic calcified subdural empyema occurring 46 years after surgery. Neuropathology 2005;25:99‑102. Access this article online Quick Response Code:

Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.121950

Received: 12‑08‑2013 Review completed: 25-08-2013 Accepted: 25‑08‑2013

Figure 1: Computed tomography scan of brain showing a thick collection of blood behind the clivus pushing the brain stem backward. Lower down, it is completely encircling the upper cervical cord

Retroclival subdural hematoma: An uncommon site of a common pathology Sir, Subdural hematomas (SDHs) of the posterior fossa are rare and there have been very few reports of retroclival SDH. Most cases of retroclival hematomas are epidural and posttraumatic. We report a case of fatal spontaneous retroclival subdural hematoma in an adult with thrombocytopenia. A 59‑year‑old lady presented with history of progressive decline in sensorium with difficulty in swallowing, articulation, and weakness of all four limbs over 2 days. She was a case of chronic kidney disease (CKD) on maintenance hemodialysis twice a week. She was also diagnosed to have chronic hepatitis, hepatitis B surface antigen positive. On examination, she was flexing both upper limbs to pain. Both plantars were extensor. On admission, patient was intubated and ventilated. Investigations revealed low platelet count [18,000/cu.mm], prothrombin time of 21.2 s, and INR (International Normalized Ratio) of 1.73. Computed tomography (CT) scan of brain revealed thick collection of blood behind the clivus pushing the brain stem backward. At lower levels, blood collection was encircling the upper cervical cord [Figure 1]. The blood extended downward from the level of the dorsum sella through the foramen magnum to the C3 body space on sagittal images. Retrocerebellar blood was also seen [Figure 2]. Laterally, the blood was more on the right side but did not extend beyond the internal acoustic meatus [Figure 3]. An acute subdural hematoma over the left frontoparietal region was also seen [Figure 4]. Transfusion of platelets and fresh frozen plasma transfusion was given; however,

550

Figure 2: Sagittal image showing blood extending downward from the level of the dorsum sella through the foramen magnum posterior to the C3 body. Retrocerebellar blood is also seen

Figure 3: Computed tomography axial imaging showing that the hematoma is more on the right side but does not extend beyond the internal acoustic meatus

her neurological condition worsened rapidly and she died within 6 h of admission.

Neurology India | Sep-Oct 2013 | Vol 61 | Issue 5

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Armored brain-massive bilateral calcified chronic subdural hematoma in a patient with ventriculoperotoneal shunt.

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