Basal ganglia calcification on computer tomographic scan. A clinical and radiological correlation

Ossified blood vessels in primary familial brain calcification elicit a neurotoxic astrocyte response

Brain calcifications are commonly detected in aged individuals and accompany numerous brain diseases, but their functional importance is not understood. In cases of primary familial brain calcification, an autosomally inherited neuropsychiatric disorder, the presence of bilateral brain calcifications in the absence of secondary causes of brain calcification is a diagnostic criterion. To date, mutations in five genes including solute carrier 20 member 2 (SLC20A2), xenotropic and polytropic retrovirus receptor 1 (XPR1), myogenesis regulating glycosidase (MYORG), platelet-derived growth factor B (PDGFB) and platelet-derived growth factor receptor β (PDGFRB), are considered causal. Previously, we have reported that mutations in PDGFB in humans are associated with primary familial brain calcification, and mice hypomorphic for PDGFB (Pdgfb^ret/ret) present with brain vessel calcifications in the deep regions of the brain that increase with age, mimicking the pathology observed in human mutation carriers. In this study, we characterize the cellular environment surrounding calcifications in Pdgfb^ret/ret animals and show that cells around vessel-associated calcifications express markers for osteoblasts, osteoclasts and osteocytes, and that bone matrix proteins are present in vessel-associated calcifications. Additionally, we also demonstrate the osteogenic environment around brain calcifications in genetically confirmed primary familial brain calcification cases. We show that calcifications cause oxidative stress in astrocytes and evoke expression of neurotoxic astrocyte markers. Similar to previously reported human primary familial brain calcification cases, we describe high interindividual variation in calcification load in Pdgfb^ret/ret animals, as assessed by ex vivo and in vivo quantification of calcifications. We also report that serum of Pdgfb^ret/ret animals does not differ in calcification propensity from control animals and that vessel calcification occurs only in the brains of Pdgfb^ret/ret animals. Notably, ossification of vessels and astrocytic neurotoxic response is associated with specific behavioural and cognitive alterations, some of which are associated with primary familial brain calcification in a subset of patients.

Fahr Syndrome - an Important Piece of a Puzzle in the Differential Diagnosis of Many Diseases

Fahr syndrome is a rare neurodegenerative disorder characterized by symmetrical, bilateral calcifications in the basal ganglia, nucleus gyrus and cerebral cortex. The continuous advancement as well as widespread use of brain imaging have contributed to the increasing detection rates of such changes. Nevertheless, their etiology is understood only partially and the methods of causative treatment are limited. Due to various symptoms, Fahr syndrome may resemble diseases from the field of neurology, psychiatry, cardiology and even urology. This article provides an up-to-date review of the literature concerning Fahr syndrome in terms of clinical practice.

Fahr's syndrome presenting with epileptic seizure: Two case reports

Fahr’s syndrome is a neuropsychiatric syndrome characterized by symmetrical and bilateral intracerebral calcifications located in the basal ganglia and usually associated with a phosphorus and calcium metabolism disorder. Clinical manifestations of Fahr’s syndrome vary; it may start at different ages and have a variety of presentations. This article discusses rare presentation of Fahr’s syndrome with epileptic seizure. These cases are important because they appear to be the first cases in the literature of Fahr’s syndrome presenting with generalized tonic clonic seizure.

Idiopathic hypoparathyroidism presenting with severe hypocalcemia and asymptomatic basal ganglia calcification followed by acute intracerebral bleed

OBJECTIVE

To report a case of idiopathic hypoparathyroidism presenting with severe hypocalcemia and intracerebral calcifications that resulted in a spontaneous intracerebral bleed.

METHODS

We present the clinical, laboratory, and radiologic findings in a woman with idiopathic hypoparathyroidism who developed spontaneous intracerebral bleed in the setting of chronic intracerebral calcifications.

RESULTS

A 37-year-old woman presented with vague symptoms of hypocalcemia. Clinical evaluation revealed brisk deep tendon reflexes and positive Chvostek's and Trousseau's signs. The serum calcium level was 3.7 mg/dL (reference range, 8.0 to 10.6 mg/dL) and the phosphorus level was 8.2 mg/dL (reference range, 2.3 to 5.0 mg/dL). Serum intact parathyroid hormone was undetectable. Computed tomography of the head showed extensive bilateral symmetrical calcification of basal ganglia and dentate nucleus in the cerebellum and centrum semiovale. Fluid and electrolytes were replaced appropriately, and calcium and calcitriol were prescribed. While in the hospital, the patient developed an acute intracerebral bleed confirmed by computed tomography. The patient recovered without neurologic sequelae and was discharged from the hospital on calcium supplementation and calcitriol. Repeated computed tomography of the head 3 years later demonstrated complete resolution of the bleed.

CONCLUSION

This case suggests that patients with severe hypoparathyroidism and intracerebral calcification may be at risk for spontaneous intracerebral bleed and should be monitored accordingly.

Mineralization of the basal ganglia: implications for neuropsychiatry, pathology and neuroimaging

This article examines the evidence for and against the existence of basal ganglia mineralization as a defined clinico-pathological entity. In reviewing the literature on basal ganglia mineralization, this article emphasizes evidence derived from different neuroimaging modalities, genetics, metabolic studies, postmortem series and their possible neuropsychiatric correlates. Relevant articles were collected through Medline and Index Medicus searches. Researchers have encountered multiple difficulties in accepting basal ganglia mineralization as a distinct entity. This syndrome lacks set clinical criteria or a unique etiology; not surprisingly, numerous articles have applied varied definitions. Because many of the reported cases have not been examined postmortem, both the extent and nature of their mineralization remains uncertain. Furthermore, researchers have considered small foci of basal ganglia mineralization a normal phenomenon of aging. However, when brain deposits are extensive, they are associated with a set of age-dependent, progressive clinical symptoms. They include cognitive impairment, extrapyramidal symptoms and psychosis. Most cases are related to abnormalities of calcium metabolism, but rare familial cases of idiopathic origin have been reported. Overabundant mineralization of the brain is judged pathological based on its amount, distribution and accompanying clinical symptoms. Although its relation with calcium dysregulation is well known, modern studies have emphasized abnormalities of iron and dopamine metabolism. The authors suggest that these metabolic abnormalities may link basal ganglia mineralization to psychotic symptomatology.

Corticobasal degeneration syndrome with basal ganglia calcification: Fahr's disease as a corticobasal look-alike?

A 57-year-old man with a 5-year history of progressive left-sided rigidity and apraxia had extensive bilateral calcification of basal ganglia, centrum semiovale, dentate nuclei, and cerebellar white matter on brain imaging. The case is an example of radiological Fahr's disease accompanying a clinical syndrome of corticobasal degeneration. Possible pathogenetic and nosological implications of this association are discussed.

The main epidemiological, clinical and morphological features of moyamoya disease in Yugoslavia

Over a period of 22 years, 31 Moyamoya cases have been recorded in Yugoslavia. In this group of the patients comprising four children and 27 adults, peak age incidence is in the third and fourth decades of life. Males and females have been almost equally affected. Familial cases or territorial clustering of the patients have not been noted. In most cases leading symptoms on admission were motor disturbances. In four patients unilateral involvement was observed while in 27 patients bilateral changes of the internal carotid artery were seen.

Cognitive and psychosocial functioning of patients with congenital nephrogenic diabetes insipidus

Mental retardation (MR) is generally considered one of the main complications of congenital nephrogenic diabetes insipidus (NDI). However, psychometric studies of NDI patients are scarce and outdated. In the present study, 17 male NDI patients underwent psychological evaluation. Total intelligence quotient of 14 patients was within (n = 13) or above (n = 1) the normal range, 1 patient had an intelligence score between -1 and -2 standard deviations (S.D.) and 2 young patients had a general cognitive index more than 2 S.D. below the norm. Attention deficit hyperactivity disorder criteria were met by 8 out of 17 patients and scores on short-term memory were low in 7 out of 10. No relation between test performances and age at diagnosis or hypernatremia could be found, with the exception of a negative correlation between age at start of therapy and verbal IQ in one age group. Although several explanations for an association between MR and NDI can be postulated, it seems that the current prevalence of MR among patients with this disease is considerably lower than suggested in literature.

MRI demonstration and CT correlation of the brain in patients with idiopathic intracerebral calcification

Twenty-two patients aged 36-63 years were diagnosed as having Fahr's syndrome on the basis of the presence on CT of unexpected extensive calcification of the basal ganglia. Even when associated with calcification of other brain areas, the main diagnostic criterion remained basal ganglia calcification larger than 800 mm2. Normal values of parathormone, serum calcium and phosphorus excluded hypercalcaemia and hypoparathyroidism. Mitochondrial CNS disease was excluded clinically. MRI and repeated CT and neurological examination were performed in all of the patients. The patients were divided into two groups: neurologically asymptomatic (group 1) and neurologically symptomatic (group 2). T2-weighted sequences demonstrated hyperintense areas in all of the patients involving the white and the grey matter of the brain. In group 1 the hyperintense lesions were significantly smaller than in group 2. The neurological symptoms correlated better with the hyperintensities on T2-weighted MR images than with the calcification demonstrated on CT. Hyperintensities in T2-weighted MRI and the areas shown by CT to have calcification had different locations. In 15 patients with dementia, the white matter of the entire centrum semiovale was bilaterally hyperintense. In another 3 patients with hemiparesis, hyperintense areas in the internal capsule, contralateral to the side of hemiparesis, were demonstrated in the T2-weighted sequence. The hyperintense T2 signals may reflect a slowly progressive, metabolic or inflammatory process in the brain which subsequently calcifies and are probably responsible for the neurological deficit observed.

[Basal ganglia calcifications in children]

We report the study of four children with bilateral basal ganglia calcifications (BGC) visualized on CT scan. Epilepsy was the clinical manifestation of three patients whose laboratory investigation revealed abnormal calcium metabolism. The first aim of this paper is to call attention to a treatable entity that can cause epileptic syndromes in infancy and childhood. The second purpose is to review the literature comparing with our fourth child who presented encephalopathy with BGC.

Diffuse encephalic calcification. A case report

The basal ganglia calcification is known since the last century but with the new neuroimage techniques (CT scan) its diagnosis became more frequent specially in asymptomatic patients. The authors report a case with non-familial primary diffuse encephalic calcification with exuberant calcifications on cerebral hemispheres, cerebellum and brain stem, seen on CT scan.

Parkinson's disease and basal ganglia calcifications: prevalence and clinico-radiological correlations

We reviewed computerized tomograms (CT) for basal ganglia and dentate nucleus calcifications in 79 patients with Parkinson's disease (PD), 54 patients with Alzheimer's disease (AD) and 109 controls aged 50 or more. When it was determined, no patient had disturbances in calcium metabolism. We found: (1) 30 subjects out of 242 (12.3%) with calcification located within the lenticular nucleus in 28. (2) Calcifications were unilateral in 11 and asymmetric in 11. (3) The prevalence of calcifications was 21.5% in PD, 9.2% in AD and 7.3% in controls and were significantly more severe in PD than in C and AD (P less than 0.02). (4) PD patients with calcifications were clinically indistinguishable from those without calcification. (5) Calcifications within the basal ganglia were not associated with a levodopa-resistance. We suggest the basal ganglia calcifications are more frequent in PD, but we cannot explain why, since post-synaptic lesions have never been showed in PD.

Familial calcification of the basal ganglia: a case report and review of the literature

Although calcification of the basal ganglia is a relatively common and asymptomatic finding on cranial computed tomography, familial idiopathic calcification of the basal ganglia (ICBG) is a rare disorder with neurological and behavioral manifestations. Attention has recently been drawn to the frequency with which cases are diagnosed as schizophrenic (Cummings et al. 1983; Lowenthal, 1986; Davison, 1987). We report a family in which a mother and son have ICBG, but while the son has a paranoid schizophrenia and intellectual deterioration, the mother shows no psychiatric illness. A review of the relevant literature suggests that psychosis is not as common as usually supposed, and may only be coincidentally associated with familial ICBG. Moreover, we find little convincing evidence that familial ICBG is an independent entity; instead, and in agreement with earlier authorities (Bruyn et al. 1964), we argue that published accounts and our own cases provide evidence that the condition is related to pseudo-hypoparathyroidism (PHP) and, therefore, may be due to a defect in a guanine nucleotide binding protein.

Neurological disorders in 166 patients with basal ganglia calcification: a statistical evaluation

Patients investigated at our institute during the last decade included 166 (1.2%) who showed uni- or bilateral basal ganglia calcification on computed tomography. We tested the significance of this neuroradiological observation by statistical comparison of these patients' clinical disorders with the findings in a random sample of 622 patients without basal ganglia calcification. The odds for the most common neurological disturbances were similar in patients with and without basal ganglia calcification. After adjustment for differences in age and brain atrophy there was no evidence of a significantly increased risk of dementia (odds ratio 1.1), cerebral infarction (1.4), epilepsy (0.9), vertigo (1.6), headache (1.8), or alcoholism (0.9), which represented the most common diagnoses. We conclude that basal ganglia calcification cannot be considered as a clinically relevant neuroradiological finding in the majority of cases and that it should not be used as an explanation for frequently observed neurological disturbances.

What is the psychiatric significance of bilateral basal ganglia mineralization?

One percent (143) of patients who underwent cranial computed tomography at the Central Institute of Mental Health during the last 10 years had bilateral basal ganglia mineralization (BGM). The relationship of this finding to the psychiatric disorders in the group was evaluated by statistical comparison with a group of patients without BGM (control group). The odds ratios for affective disorders and for organic brain syndromes with affective or paranoid symptoms showed a mild, but statistically significant, increase in patients with BGM. There was no evidence of an increased proportion of dementia, schizophrenia, or alcoholism in those with BGM. Those with BGM had a higher mean age and significantly more cortical atrophy and ventricular enlargement than did patients without. These confounding variables contributed to clinical differences between the BGM and the control groups.

No difference in basal ganglia mineralization between schizophrenic and nonschizophrenic patients: a quantitative computerized tomographic study

The role of iron in schizophrenia (SC) has aroused attention because of its modulatory effect on the dopamine receptor and its role as a cofactor for tyrosine hydroxylase. In addition, several postmortem studies suggest that increased mineralization (especially iron) of the basal ganglia is a possible clinicopathological correlate of schizophrenia. In order to quantitate the in vivo mineral content in the basal ganglia of patients with SC, a protocol was developed to analyze CT scans films with a LOATS computer analysis system. A total of 725 consecutive CT scans (275 SC, 450 nonSC) from a psychiatric population were reviewed. Eighteen scans (2.3%) revealed basal ganglia mineralization of which 7 cases carried a diagnosis of SC and 11 had other psychiatric disorders. All subjects had received neuroleptics, and 8 of the 11 patients in the nonschizophrenic group were demented. Both the SC and nonSC patients exhibited a prevalence (2.5%) of basal ganglia mineralization similar to that found in a postmortem series of the general population.

Some rare causes of intracranial calcification in childhood: computed tomographic findings

The CT findings in 36 cases of childhood intracranial calcification were analysed. Tuberous sclerosis was the commonest disease, predisposing to calcifications that were essentially nodular in type and bilaterally periventricular in distribution. Calcifications were also noted in other common diseases such as tuberculoma and osteopetrosis, and after meningitis. There were three cases of osteopetrosis with intracranial calcifications: one had calcifications in the peritentorial region and two in the junction regions between the grey and white matters with basal ganglia. These observations were previously unreported. The presence of basal ganglia calcification in Down syndrome is also reported. Most calcifications were not visualized on plain radiographs. Our study shows that if the CT attenuation values are less than 200 Hounsfield units (HU), the calcifications are not visualized on the plain radiographs.

Contribution of CT scan to the diagnosis of Fahr's syndrome

Of 7040 patients who were examined with CT scan for various reasons, 72 (1.02%) showed symmetrical intracranial calcifications. On the basis of the extent of the calcifications, the patients were divided into 3 groups of which the first (10 cases), with extensive calcifications, showed clear findings of hypoparathyroidism; the second (4 cases), with less extensive calcifications, showed borderline laboratory findings and the third (58 cases), with calcifications only in the internal part of the globus pallidus, had no relation to any disturbance of the parathyroid function. The limited percentage (4.2%) of calcifications detected by ordinary cranial X-rays was discussed as compared to those diagnosed by CT scan; this is due to the weakening of the relationship which existed in the past between hypoparathyroidism and calcifications. Patients with extensive calcifications do not seem to have a significantly higher proportion of neurological impairment (35.8%) than patients who showed limited calcifications (34.5%). On the other hand, patients with extensive calcifications showed more frequent mental disorders (50%) compared to those who showed limited calcifications (34.5%). The proportion of mental disorders is still higher in patients with dilatation of the subarachnoid spaces (56.7%) compared to those who do not show dilatation (23.8%). Finally, of the 72 patients with calcifications, 15 (20.8%) showed extrapyramidal syndrome, possibly due to calcium salt deposits in the metasynaptic dopamine receptors while 13 (18%) were taking anticonvulsant drugs which, apart from influencing the metabolism of calcium, also influence the activity of alkaline phosphatase and are involved in the creation of calcifications.

Prevalences of CT-detected calcification in the basal ganglia in idiopathic hypoparathyroidism and pseudohypoparathyroidism

Sixteen patients with idiopathic hypoparathyroidism (IHP) and eight patients with pseudohypoparathyroidism (PHP) were examined by CT scan of the brain. Calcification in the basal ganglia was observed in 11 patients with IHP (69%) and in all eight patients with PHP. Of the 19 patients with basal ganglia calcification, nine had calcification in the cerebral cortex (47%), and four had calcification in the cerebellum (21%). Observation of basal ganglia calcification on CT gave rise to suspicion of IHP or PHP in three patients (12%). The remaining patients were examined at varying time after diagnosis. Since arrest in growth of calcification after institution of treatment has never been proven, the reported prevalences of calcification may not be valid to the situation at the time of diagnosis.

Intracranial bilateral symmetrical calcification on CT-scanning. A case report and a review of the literature

The case of a 57-year-old woman with idiopathic hypoparathyroidism is presented. A CT-scan showed extensive bilateral symmetrical calcification in the region of the basal ganglia, nuclei of the cerebellum and the cerebral and cerebellar white matter. A review of the literature showed that bilateral symmetrical calcification detected by CT is usually small in extent and is most often confined to the globus pallidus. It is most commonly found in patients older than 50 years, who only rarely have symptoms associated with it. The finding is, though, non-specific and may occur in a variety of pathological conditions both with and without an aetiological relationship. Further study of the cerebral parathormone responsive adenylate cyclase enzyme proves hopeful to elucidate the aetiology of idiopathic bilateral symmetrical calcification.