British Journal of Neurosurgery, February 2015; 29(1): 85–86 © 2014 The Neurosurgical Foundation ISSN: 0268-8697 print / ISSN 1360-046X online DOI: 10.3109/02688697.2014.952267
SHORT REPORT
Gigantic ossified chronic epidural haematoma and contralateral postoperative subdural haematoma: A case report and literature review Wenlong Zhang, Wei Zhang, Zhixian Gao & Jiangfei Wang
Br J Neurosurg Downloaded from informahealthcare.com by Nyu Medical Center on 06/08/15 For personal use only.
Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
Abstract A 21-year-old woman was found to have a dramatic intracranial space-occupying lesion found via CT scan performed to investigate headache. Craniotomy was performed and the mass found to be a chronic extradural haematoma, whose aetiology was likely to have been spontaneous, due to thrombocytopenia in infancy. Although this was removed, her recovery was complicated by the need to treat a contralateral delayed subdural haematoma.
Post-operative course and follow-up The patient had a left-sided weakness immediately after the operation which improved over the next 20 days. MRI and some CT scans were performed postoperatively (Fig. 3). She was readmitted to hospital 2 months after the first craniotomy. A contralateral delayed subdural haematoma had been found when she was reviewed at the hospital (Fig. 4A), but there was no related symptom such as headache or neurological deficit. Approximately 80 ml of fluid was drained, following which she made a good recovery. A postoperative CT scan demonstrated satisfactory resolution of the haematoma (Fig. 4B). At one year she has made a complete recovery and has no neurological deficit.
Keywords: accidental; craniotomy; chronic epidural haematoma; subdural haematoma
Clinical details History and examination A 21-year-old woman presented with history of headache for many years, and a presumed diagnosis of nasosinusitis. There were no other symptoms referable to the central nervous system. Neurologic examination and haematological analyses were normal, including assessment of coagulation status. There was no prior history of seizures, loss of consciousness or trauma, though in retrospect a history of thrombocytopenic purpura was obtained. Computed tomography (CT) and magnetic resonance imaging (MRI) showed the dramatic lesion displayed in Fig. 1.
Operation At craniotomy a soft, dark yellow mass was identified with an ossified outer shell. There was hyperplasia of the skull whilst the inner side of the shell was attached to the dura but wholly extradural. (Fig. 2A–C). The removal of the ossified tissue was hard for the partly adhesion of the shell, dura and cortex. The ossified shell and the mass were completely removed. The diagnosis of a long-standing organized haematoma with calcification was confirmed pathologically (Fig. 2D).
Fig. 1. A series of imaging information. (A) Non-contrasted head CT showing a large right intracranial mass with uneven calcification in and around it. (B–D) Composite of MRI showing a giant mixed signals lesion with clear margin.
Correspondence: Jiangfei Wang, MD, Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.6 Tiantanxili, Dongcheng District, Beijing, P. R. China. Tel: ⫹ 8613911994320. Fax: ⫹ 8610 65113440. E-mail: [email protected] Received for publication 19 February 2014; accepted 2 August 2014
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Br J Neurosurg Downloaded from informahealthcare.com by Nyu Medical Center on 06/08/15 For personal use only.
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W. Zhang et al.
Fig. 2. Intraoperative photographs & postoperative pathological image. (A) A soft, dark yellow mass is under the right side of the skull. (B) After the removing of the mass, a completely ossified inner shell of the haematoma appears. (C) The outer ossified shell of the haematoma and the skull flap with local thickening. (D) Postoperative microscopic pathological image shows an old haematoma with organization and calcification.
Discussion Chronic EDHs with calcification and ossification are rare clinical entities, and this is a dramatic example, of a
Fig. 3. MRI and CT scan are performed postoperatively. (A) MRI performed 15 days after operation. (B) CT performed 13 days after the first operation.
mass lesion that in its acute stage would be expected to produce dramatic symptoms, though no history of such was obtained. The most common aetiology of EDHs is head trauma.1 Less commonly, ventricular drainage – especially for chronic hydrocephalus – or craniotomy for mass lesion can result in EDH. Finally blood dyscrasias may cause spontaneous EDH.2,3 This last hypothesis seems the most likely as she was discovered to have a history of thrombocytopenic purpura when she was aged 2 months. Given the ossification, the lack of a history of trauma, and her good condition despite the dramatic appearances, it seems reasonable to conclude that the lesion was related to the thrombocytocenic state, and perhaps in origin contemporaneous with it, which might explain how such a dramitc lesion could develop apparently unnoticed. The delayed presentation of the contralateral sub-dural is not too suprising given the size of the chronic sub-dural; it is gratifying, however, that a complete recovery occurred. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References
Fig. 4. Pre- and post-operative CT scan of delayed subdural haematoma. (A) A huge left frontal chronic subdural haematoma. (B) A CT scan showing a completely evacuation of the subdural haematoma.
1. Bonilha L, Mattos JP, Borges WA , et al. Chronic epidural haematoma of the vertex. Clin Neurol Neurosurg 2003;106:69–73. 2. Ng WH, Yeo TT, Seow WT. Non-traumatic spontaneous acute epidural haematoma – report of two cases and review of the literature. J Clin Neurosci 2004;11:791–3. 3. Vural M, Yarar C, Durmaz R, Atasoy MA . Spontaneous acute subdural haematoma and chronic epidural haematoma in a child with F XIII deficiency. J Emerg Med 2010;38:25–9.
SHORT REPORT
Gigantic ossified chronic epidural haematoma and contralateral postoperative subdural haematoma: A case report and literature review Wenlong Zhang, Wei Zhang, Zhixian Gao & Jiangfei Wang
Br J Neurosurg Downloaded from informahealthcare.com by Nyu Medical Center on 06/08/15 For personal use only.
Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, P. R. China
Abstract A 21-year-old woman was found to have a dramatic intracranial space-occupying lesion found via CT scan performed to investigate headache. Craniotomy was performed and the mass found to be a chronic extradural haematoma, whose aetiology was likely to have been spontaneous, due to thrombocytopenia in infancy. Although this was removed, her recovery was complicated by the need to treat a contralateral delayed subdural haematoma.
Post-operative course and follow-up The patient had a left-sided weakness immediately after the operation which improved over the next 20 days. MRI and some CT scans were performed postoperatively (Fig. 3). She was readmitted to hospital 2 months after the first craniotomy. A contralateral delayed subdural haematoma had been found when she was reviewed at the hospital (Fig. 4A), but there was no related symptom such as headache or neurological deficit. Approximately 80 ml of fluid was drained, following which she made a good recovery. A postoperative CT scan demonstrated satisfactory resolution of the haematoma (Fig. 4B). At one year she has made a complete recovery and has no neurological deficit.
Keywords: accidental; craniotomy; chronic epidural haematoma; subdural haematoma
Clinical details History and examination A 21-year-old woman presented with history of headache for many years, and a presumed diagnosis of nasosinusitis. There were no other symptoms referable to the central nervous system. Neurologic examination and haematological analyses were normal, including assessment of coagulation status. There was no prior history of seizures, loss of consciousness or trauma, though in retrospect a history of thrombocytopenic purpura was obtained. Computed tomography (CT) and magnetic resonance imaging (MRI) showed the dramatic lesion displayed in Fig. 1.
Operation At craniotomy a soft, dark yellow mass was identified with an ossified outer shell. There was hyperplasia of the skull whilst the inner side of the shell was attached to the dura but wholly extradural. (Fig. 2A–C). The removal of the ossified tissue was hard for the partly adhesion of the shell, dura and cortex. The ossified shell and the mass were completely removed. The diagnosis of a long-standing organized haematoma with calcification was confirmed pathologically (Fig. 2D).
Fig. 1. A series of imaging information. (A) Non-contrasted head CT showing a large right intracranial mass with uneven calcification in and around it. (B–D) Composite of MRI showing a giant mixed signals lesion with clear margin.
Correspondence: Jiangfei Wang, MD, Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, No.6 Tiantanxili, Dongcheng District, Beijing, P. R. China. Tel: ⫹ 8613911994320. Fax: ⫹ 8610 65113440. E-mail: [email protected] Received for publication 19 February 2014; accepted 2 August 2014
85
Br J Neurosurg Downloaded from informahealthcare.com by Nyu Medical Center on 06/08/15 For personal use only.
86
W. Zhang et al.
Fig. 2. Intraoperative photographs & postoperative pathological image. (A) A soft, dark yellow mass is under the right side of the skull. (B) After the removing of the mass, a completely ossified inner shell of the haematoma appears. (C) The outer ossified shell of the haematoma and the skull flap with local thickening. (D) Postoperative microscopic pathological image shows an old haematoma with organization and calcification.
Discussion Chronic EDHs with calcification and ossification are rare clinical entities, and this is a dramatic example, of a
Fig. 3. MRI and CT scan are performed postoperatively. (A) MRI performed 15 days after operation. (B) CT performed 13 days after the first operation.
mass lesion that in its acute stage would be expected to produce dramatic symptoms, though no history of such was obtained. The most common aetiology of EDHs is head trauma.1 Less commonly, ventricular drainage – especially for chronic hydrocephalus – or craniotomy for mass lesion can result in EDH. Finally blood dyscrasias may cause spontaneous EDH.2,3 This last hypothesis seems the most likely as she was discovered to have a history of thrombocytopenic purpura when she was aged 2 months. Given the ossification, the lack of a history of trauma, and her good condition despite the dramatic appearances, it seems reasonable to conclude that the lesion was related to the thrombocytocenic state, and perhaps in origin contemporaneous with it, which might explain how such a dramitc lesion could develop apparently unnoticed. The delayed presentation of the contralateral sub-dural is not too suprising given the size of the chronic sub-dural; it is gratifying, however, that a complete recovery occurred. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References
Fig. 4. Pre- and post-operative CT scan of delayed subdural haematoma. (A) A huge left frontal chronic subdural haematoma. (B) A CT scan showing a completely evacuation of the subdural haematoma.
1. Bonilha L, Mattos JP, Borges WA , et al. Chronic epidural haematoma of the vertex. Clin Neurol Neurosurg 2003;106:69–73. 2. Ng WH, Yeo TT, Seow WT. Non-traumatic spontaneous acute epidural haematoma – report of two cases and review of the literature. J Clin Neurosci 2004;11:791–3. 3. Vural M, Yarar C, Durmaz R, Atasoy MA . Spontaneous acute subdural haematoma and chronic epidural haematoma in a child with F XIII deficiency. J Emerg Med 2010;38:25–9.
