Figure 1
axial cut CT Brain
Basal ganglia calcification
Brain parenchymal calcification in Down
SectionPaediatric radiology
Case TypeClinical Cases
AuthorsMai A.Mostafa
Connected authors
10 years, male
Clinical History
A 10-year-old boy presented with disturbed conscious levels. On examination there were bilateral pin-point pupils. CT brain was undertaken to exclude pontine haemorrhage.
Imaging Findings
Brain CT revealed a normal pons (Fig1), but also demonstrated bilateral almost symmetrical basal ganglia calcification (Fig2) and scattered supratentorial curvilinear calcifications within the subcortical U fibres (Fig3).
Discussion
Pathological intracranial calcification (ICC) is a common finding in the paediatric age group and can be detected on computed tomography. (1)
The diagnostic approach to intracranial calcification (2) includes:
(1) Is calcification present?
(2) Is there a brain malformation or atrophy?
(3) Is the white matter abnormal? If so, can the leukoencephalopathy be characterized further and a diagnostic pattern suggested.?
(4) Are there other radiological features, such as the presence of contrast enhancement, cysts or vascular abnormalities, that add further diagnostic information in selected cases?
One of the common causes of intracranial calcification in the paediatric age group is focal calcification occurring in damaged or neoplastic brain tissue, which may be present in both malignant or benign neoplasms. It usually indicates chronicity. However, the occurrence of calcification in malignant tumours indicates either that ICC may appear rapidly or that the presenting tumour represents a slower growing neoplasm that has undergone malignant transformation. Calcification within the basal ganglia or other brain regions is not uncommon following radiotherapy for treatment of a brain tumour, and has also been described in patients treated for leukaemia with combined cranial radiation and methotrexate. (2)
Dystrophic calcification, particularly in the cerebral cortex, is seen following brain damage due to bacterial meningitis, encephalitis, hypoxic–ischaemic injury, and sometimes following ischaemic stroke.(2)
Hyper-, hypo-, and pseudohypoparathyroidism show rather symmetrical basal ganglia and thalamic calcification, often accompanied by deep gyral calcification. (2)
There are other differential diagnoses for intracranial calcification such as congenital infection, nephrogenic and central diabetes insipidus, and vascular malformations. (2)
Down syndrome is a rare cause of intracranial calcification and its pathogenesis is still unknown. (3)
Previous histological studies in Down patients reveal that basal ganglia calcification occurs in the pericapillary and media of small arteries, but the nerve cells remain unchanged. (4)
The diagnostic approach to intracranial calcification (2) includes:
(1) Is calcification present?
(2) Is there a brain malformation or atrophy?
(3) Is the white matter abnormal? If so, can the leukoencephalopathy be characterized further and a diagnostic pattern suggested.?
(4) Are there other radiological features, such as the presence of contrast enhancement, cysts or vascular abnormalities, that add further diagnostic information in selected cases?
One of the common causes of intracranial calcification in the paediatric age group is focal calcification occurring in damaged or neoplastic brain tissue, which may be present in both malignant or benign neoplasms. It usually indicates chronicity. However, the occurrence of calcification in malignant tumours indicates either that ICC may appear rapidly or that the presenting tumour represents a slower growing neoplasm that has undergone malignant transformation. Calcification within the basal ganglia or other brain regions is not uncommon following radiotherapy for treatment of a brain tumour, and has also been described in patients treated for leukaemia with combined cranial radiation and methotrexate. (2)
Dystrophic calcification, particularly in the cerebral cortex, is seen following brain damage due to bacterial meningitis, encephalitis, hypoxic–ischaemic injury, and sometimes following ischaemic stroke.(2)
Hyper-, hypo-, and pseudohypoparathyroidism show rather symmetrical basal ganglia and thalamic calcification, often accompanied by deep gyral calcification. (2)
There are other differential diagnoses for intracranial calcification such as congenital infection, nephrogenic and central diabetes insipidus, and vascular malformations. (2)
Down syndrome is a rare cause of intracranial calcification and its pathogenesis is still unknown. (3)
Previous histological studies in Down patients reveal that basal ganglia calcification occurs in the pericapillary and media of small arteries, but the nerve cells remain unchanged. (4)
Differential Diagnosis List
Basal ganglionic and subcortical U white matter calcification in Down patient.
Hypoparathyroidism
Pseudohypoparathyroidism
Final Diagnosis
Basal ganglionic and subcortical U white matter calcification in Down patient.
References
[1] Erdem E1, Ağildere M, Eryilmaz M, Ozdirim E. (1994) Intracranial calcification in children on computed tomography. Turk J Pediatr ;36(2):111-22. (PMID: 8016912)
[2] Livingston J, Stivaros S, Warren D, Crow Y. (2013) . Intracranial calcification in childhood: a review of aetiologies and recognizable phenotypes. Developmental Medicine & Child Neurology ;56(7):612-626. (PMID: 24372060)
[3] Sadana KS, Goraya JS. (2018) Intracranial Calcification in Down Syndrome. . Journal of Pediatric Neurosciences ;13(1):120-121. (PMID: 29899789)
[4] Takashima S, Becker LE. (1985) Basal ganglia calcification in Down’s syndrome. Journal of Neurology, Neurosurgery, and Psychiatry ;48(1):61-64 . (PMID: 3156213)
Case information
| URL: | https://eurorad.org/case/16297 |
| DOI: | 10.1594/EURORAD/CASE.16297 |
| ISSN: | 1563-4086 |
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Figure 2
axial cut CT Brain
Subcortical white matter calcification
Figure 3
axial cut CT Brain
No evidence of pontine hemorrhage.
axial cut CT Brain
Basal ganglia calcification
Radiology department ,El Demerdash Hospital,Ain Shams university .
Radiology department ,El Demerdash Hospital,Ain Shams university .
axial cut CT Brain
Subcortical white matter calcification
Radiology department ,El Demerdash Hospital,Ain Shams university .
Radiology department ,El Demerdash Hospital,Ain Shams university .
axial cut CT Brain
No evidence of pontine hemorrhage.
Radiology department , El-Demerdash hospital ,Ain Shams university
Radiology department , El-Demerdash hospital ,Ain Shams university