Calcification of the basal ganglia as a cause of levodopa-resistant parkinsonism

Hyperparathyroidism and cerebral calcifications:a case report

The evidence of hyperparathyroidism associated with cerebral calcifications is rare. We report a case with primary hyperparathyroidism (PHPT) and cerebral calcifications. A 63-year-old female patient with a history of hypertension presented to the neurology department due to bradykinesia and declining memory for one year.   Cranial CT and magnetic resonance imaging (MRI) scan revealed symmetrical calcifications in the basal ganglia, dentate nucleus of the cerebellum and in the gray and white matter junction. In the literature review, a total of 6 patients with PHPT had cerebral calcifications. Parathyroidectomy may provide a significant remission of cerebral calcifications in a patient with PHPT.

PARKINSONISM AS AN ATYPICAL MANIFESTATION OF PRIMARY HYPERPARATHYROIDISM

OBJECTIVE

Primary hyperparathyroidism (PHPT) occurs as a result of hyperfunctional parathyroid glands resulting in an elevation of serum calcium levels. The association between hypoparathyroidism and parkinsonism have been frequently reported in the literature, while evidence of hyperparathyroidism associated with parkinsonism is rare.

METHODS

The present study reports a case of a patient that had PHPT and developed symptoms of parkinsonism.

RESULTS

A 75-year-old female patient with a history of diabetes mellitus, dyslipidemia, and systemic arterial hypertension presented to the emergency room due to unexplained drowsiness. Her serum calcium at the time was 14.2 mg/dL. A cervical ultrasound was performed, and the presence of a 2.5 × 1.9-cm nodule in the left lower parathyroid region was identified. Three days later, scintigraphy with the use of sestamibi showed an increased capture of the marker in the same region, suggesting parathyroid hyperfunction. During hospitalization, the patient developed symptoms of parkinsonism. A left inferior parathyroidectomy was performed, with normalization of serum calcium levels and a remission of drowsiness, in addition to a significant improvement in parkinsonian symptoms. The patient remained free of parkinsonism over 3 years of follow up.

CONCLUSION

Parathyroidectomy can provide a significant remission of parkinsonism in a patient with PHPT. Even though it is rare, the relation between parkinsonism and PHPT exists.

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.

[Striatopallidodentate calcinosis, hypoparathyroidism and neurological features: a case series study]

INTRODUCTION

The respective roles of hypocalcemia and intracerebral calcifications in the occurrence of various neurological manifestations in hypoparathyroidism is not entirely clear. Nevertheless, therapeutic and prognostic implications are important.

OBJECTIVES

We analyze the neurological clinical aspects observed in hypoparathyroidism and correlate them to the biological calcium abnormality and radiological CT scan findings. We also compare these results with data reported in the idiopathic form of striatopallidodentate calcinosis.

PATIENTS

The neurological clinical, CT scan findings and outcome have been retrospectively studied in patients recruited during 13 years (2000-2012) for neurological features associated with hypoparathyroidism or pseudohypoparathyroidism.

RESULTS

Twelve patients with primary hypoparathyroidism (n=5), secondary to thyroidectomy (n=4) and pseudohypoparathyroidism (n=3) were studied. The sex-ratio was 1 and mean age was 39 years. All patients had a tetany, 60% had epilepsy, associated in one patient with "benign" intracranial hypertension; 50% had behavioral changes. Response to calcium therapy was excellent for all these events. Moderate cognitive deficit was noted in three patients (25%), parkinsonism in two patients and hyperkinetic movement disorders in one other. These events were not responsive to calcium therapy and were more common in cases of extensive brain calcifications and in patients who had pseudohypoparathroidism.

COMMENTS

This study suggests that, in patients with hypoparathyroidism, epilepsy and psychiatric disorders are induced by hypocalcemia and reversible after its correction. Cognitive and extrapyramidal impairment seem to be related to the progressive extension of intracerebral calcification, particularly in patients with a late diagnosis. In patients with pseudohypoparathyroidism, this finding is different because of the contribution of other factors, specific to this disease.

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.

What is and what is not 'Fahr's disease'

Bilateral almost symmetric calcification involving striatum, pallidum with or without deposits in dentate nucleus, thalamus and white matter is reported from asymptomatic individuals to a variety of neurological conditions including autosomal dominant inheritance to pseudo-pseudohypoparathyroidism. While bilateral striopallidodentate calcinosis is commonly referred to as 'Fahr's disease' (a misnomer), there are 35 additional names used in the literature for the same condition. Secondary bilateral calcification is also reported in a variety of genetic, developmental, metabolic, infectious and other conditions. In autosomal dominant or sporadic bilateral striopallidodentate calcinosis no known calcium metabolism abnormalities are known to date. Clinically, parkinsonism or other movement disorders appear to be the most common presentation, followed by cognitive impairment and ataxia. When presence of movement disorder, cognitive impairment and ataxia are present, a computed tomography scan of the head should be considered to rule-in or rule-out calcium deposits. Calcium and other mineral deposits cannot be linked to a single chromosomal locus. Further genetic studies to identify the chromosomal locus for the disease are in progress.

Systemic diseases that cause movement disorders

The present review is aimed at providing practical assistance to the clinical neurologist in reaching a diagnosis, understanding the pathogenic mechanisms of movement disorders associated with systemic diseases, and determining appropriate therapy. Infectious disease by direct effect or as an acquired autoimmune neurological disease, stroke, hypoxia-ischemia, paraneoplastic syndromes, collagen disorders, endocrine, liver and kidney diseases that may cause hypokinetic or hyperkinetic abnormal movement are considered separately. The type and evolution of abnormal movement caused by systemic disease vary with age and underlying pathology. Therapy for abnormal movements should include a primary treatment for the systemic disease.

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.

Parkinsonism associated with autosomal dominant bilateral striopallidodentate calcinosis

Bilateral striopallidodentate calcinosis (BSPDC, also known as Fahr's disease, a misnomer), is a rare disorder where bilateral, almost symmetric, calcium and other mineral deposits occur in subcortical nuclei and white matter. Neurological manifestations vary but movement disorders are the most common. Of the movement disorders, parkinsonism predominates. We describe 6 patients with BSPDC associated with parkinsonism. Of the 6 patients, one patient from an autosomal dominantly inherited family who responded to levodopa, showed Lewy bodies in substantia nigra neurons and changes consistent with BSPDC. Another patient, from the same family with clinical evidence of parkinsonism and radiological and neuropathological evidence of BSPDC, did not show Lewy bodies. Ten patients with BSPDC and parkinsonism (without evidence of parathyroid dysfunction) were found in the literature. When parkinsonism is associated with dementia and cerebellar signs, obtaining a CT scan may be helpful as BSPDC often presents with the above three conditions.

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.

Skeletal dysplasia, intracerebral calcifications, optic atrophy, hearing impairment, and mental retardation: nosology of dysosteosclerosis

A girl who presented at 3 months of life with severe developmental delay, blindness, and hearing impairment was found to have intracerebral calcifications. Skeletal films showed craniotubular bone modeling consistent with dysosteosclerosis. The nosology of this disorder is discussed.

Bilateral striopallidodentate calcinosis: cerebrospinal fluid, imaging, and electrophysiological studies

We report the genetic, clinical, electrophysiological, and imaging studies in a family with bilateral striopallidodentate calcinosis (Fahr's disease). The intracerebral calcium deposits occurred before onset of the symptoms in the third decade of life. Progressive neurological deterioration occurred in the fifth decade of life in the proband. Cerebrospinal fluid homocarnosine, a central nervous system-specific peptide, was increased twofold in patients with autosomal dominant bilateral stripallidodentate calcinosis; in sporadic cases, there was no detectable homocarnosine and a decreased level of histidine. With advancing age, the amount of calcification increases, but it has not been determined if a critical amount must be reached before symptoms occur. Computerized tomography is superior to magnetic resonance imaging for radiological diagnosis. Despite diffuse striatal calcification, striatal 6-[18F]fluoro-L-dopa uptake did not reveal any difference between patients and control subjects, from which we infer persisting integrity of the nigrostriatal dopaminergic pathway.

Case report: extensive brain calcification in hypoparathyroidism

It is well known that most patients with hypoparathyroidism have radiologically detectable basal ganglia calcification. Not as well known is that the brain calcinosis may be more extensive. We describe a 55-year-old woman with a 44-year history of symptomatic idiopathic hypoparathyroidism who has extensive calcification of her cerebrum and cerebellum as well as her basal ganglia, evident on computed tomography of the head. When first evaluated here 32 years ago, plain radiography of the skull demonstrated calcification of both caudate and lentiform nuclei (basal ganglia). Despite fair control of her serum calcium level, she has developed focal seizures, possibly related to the calcinosis of her brain.

Intracerebral bilateral symmetrical calcifications, demonstrated in a patient with pseudohypoparathyroidism

Bilateral Symmetrical Calcifications (B.S.C.) in cerebro represent calcium deposits usually found in the basal ganglia and/or dentate nucleus. They can be the result of diverse disorders, but can also present themselves without any underlying disease. Most often they are asymptomatic, but if the calcifications are extensive, extrapyramidal and cerebellar signs may arise. The following case concerns a patient with pseudohypoparathyroidism. Besides the usual signs and symptoms found in this disease, the patient also showed extensive B.S.C. The etiology and clinical symptoms of B.S.C. will be discussed. Furthermore, attention will be given to the syndrome of the pseudohypoparathyroidism and the effects of hypocalcemia.

Juvenile Parkinsonism: clinical and metabolic characteristics

Twenty one patients with idiopathic Parkinsonism beginning before the age of 40 years were investigated. The mean duration of the disease was 19 years. There was a good and sustained response to levodopa. Only four patients reached stages IV and V (Hoehn and Yahr). Intolerance to levodopa was observed in the more advanced stages of the disease. In the series the familial incidence of Parkinsonism (2 cases) and essential tremor (3 cases) was very low. Thyroid disorder, diabetes mellitus or macrocytic anaemia was not found in any of the cases.

Amantadine for levodopa resistant parkinsonism

A 65-year-old woman with stigmata of Parkinsonism was resistant to therapy with levodopa, bromocriptine and anticholinergics. However, administration of amantadine (Symmetrel), (200 mg/day) produced significant improvement in her motor disability as well as in her mental status. The mechanisms of amantadine's therapeutic effects in this unusual case are discussed.

Unusual cases of presenile dementia with Fahr's syndrome

Three patients with an unusual type of presenile dementia were studied. Atypical clinical pictures emerged from an evaluation of these cases. Their symptoms and signs were thought to be neither those of Alzheimer's disease nor those of Pick's disease but a partial mixture of those of both diseases. The neuropathological changes were characteristic and the common findings were as as follows: the absence of senile plaques, the widespread presence of numerous neurofibrillary tangles, a calcareous deposition of Fahr's type, a circumscribed cerebral atrophy in the temporal or/and frontal lobes, a moderate or severe demyelination and fibrous gliosis in the white matter of the atrophied areas, and a slight or moderate neuronal loss in the nucleus basalis of Meynert. Similar cases reported previously were reviewed.

Parkinsonism, basal ganglia calcification and epilepsy as late complications of postoperative hypoparathyroidism

A patient with post-thyroidectomy hypoparathyroidism, basal ganglia calcification, parkinsonism and seizures is reported. The parkinsonism was resistant to levodopa therapy but was not significantly improved by the correction of hypoparathyroidism. Previously reported cases are discussed, as well as the relationship between hypoparathyroidism, calcification of basal ganglia, parkinsonism and epilepsy.

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.

Calcification of basal ganglia, postoperative hypoparathyroidism and extrapyramidal, cerebellar, pyramidal motor manifestations

A patient is described who 32 years after thyroidectomy developed a chronic progressive syndrome due to hypoparathyroidism, with multiple extrapyramidal signs (faciobuccolingual dyskinesias, choreiform and athetotic movements of upper extremities, tremor of hands, cogwheel phenomenon), cerebellar manifestations (dysarthria, dysgraphia, mild gait ataxia), and pyramidal signs as well as an organic psychosis and epilepsy. A CT scan showed calcification of the basal ganglia. Therapy for hypoparathyroidism produced partial regression of the disorder. To explain the physiopathologic mechanism of the syndrome, Selye et al. advanced an attractive hypothesis of calciphylaxis, which assumes that a sensitizer and a challenger together induce development of calcification. In the case reported calcification involved the periventricular region and was not limited to the basal ganglia. It is suggested that either a sensitizer or a challenger may enter the periventricular tissue via the ependyma.

Calcification of the basal ganglia following carbon monoxide poisoning

Minor calcification of the basal ganglia was demonstrated by computed tomography in a woman, aged 66, who had survived carbon monoxide poisoning 48 years earlier. Extensive neuropathological investigations have demonstrated calcified lesions of the basal ganglia in a number of conditions, but their frequency and topographic distribution in vivo remain to be elucidated, by means of CT.

Bilateral basal ganglia calcifications visualised on CT scan

Thirty-eight cases of basal ganglia calcification imaged on computed axial tomography were reviewed. Most cases were felt to represent senescent calcification. The possibility of a vascular aetiology in this group is discussed. A less common group of patients was identified with calcification secondary to abnormalities in calcium metabolism or radiation therapy. Three cases of basal ganglia calcifications were detected in juvenile epileptic patients receiving chronic anticonvulsants. These cases may be related to abnormalities in calcium metabolism and alkaline phosphatase activity. Clinical evidence of basal ganglia abnormality was generally absent demonstrating the preservation of neuronal pathways in most cases.

Hypoparathyroidism

Recent advances in our understanding of the physiologic actions of PTH and vitamin D have clarified certain aspects of the pathogenesis, classification, and management of hypoparathyroidism. Central to pathogenesis and categorization is the recognition that hypoparathyroidism may result from PTH deficiency, ineffectiveness, or resistance, with a resultant inability to stimulate adenylate cyclase in target tissues. This aberration in adenylate cyclase activity impairs certain physiologic responses such as renal phosphate excretion and renal calcium reabsorption that are required for proper calcium homeostasis. Also critical is the subnormal production of 1 alpha,25-dihydroxycholecalciferol (1,25-DHCC). Although the precise mechanism for the deficiency of 1,25-DHCC remains unclear, one may hypothesize that in hormone-deficient or hormone-ineffective hypoparathyroidism, decreased synthesis results from the absence of the two recognized stimuli for 1 alpha-hydroxylase--bioactive PTH and hypophosphatemia. Provision of either one of these stimuli would then be expected to restore 1,25-DHCC to normal levels, which could explain the calcemic response to PTH in these patients. There is some evidence that the synthesis of 1,25-DHCC may be "primarily" affected in PTH-resistant hypoparathyroidism, and thus may be unresponsive to any of the known stimuli. It remains conceivable, however, that during normocalcemic phases, such patients may improve their renal cyclic AMP and phosphaturic responses to PTH, with associated improvement in 1,25-DHCC synthesis. Certain acquired forms of PTH resistance such as hypomagnesemia and end-stage renal disease may also be associated with defective 1-hydroxylation. Whether occurring primarily or as a secondary process, the subnormal production of 1,25-DHCC may influence calcium and skeletal metabolism directly or by modifying response to PTH. The availability of 1,25-DHCC provides an effective and physiologically meaningful mode of therapy for most cases of hypoparathyroidism.

Hypocalcaemic chorea secondary to malabsorption

A patient presented with chorea and a recent history of Crohn's disease. Investigation revealed the cause of the chorea to be hypocalcaemia secondary to malabsorption. So far as is known there has been no previous report of hypocalcaemic chorea due to malabsorption.

Bromocriptine in lieu of levodopa for Parkinson's disease

Thirteen patients with Parkinson's disease, whose disability was increasing and on long-term levodopa therapy (both with and without carbidopa), had the levodopa fully replaced by bromocriptine. At three months, eight of the 13 patients (62%) were less disabled on bromocriptine and none became worse. The present indications for the use of bromocriptine are discussed.

Significance of genetic factors in Gilles de la Tourette syndrome: a review

Observations suggesting a genetic basis for Gilles de la Tourette syndrome are reviewed with particular emphasis on the finding of familial aggregation. Studies of both Tourette syndrome and simple tic have found that approximately 30% of patients have a positive family history of tic. The significance of this figure depends on a number of factors, in particular the prevalence of positive tic histories in the population. If the latter figure is 10%, which the best available evidence suggests is a reasonable estimate, approximately 30% of families in the general population would be expected to contain at least one present or former tiquer. It is argued, therefore, that the family aggregation findings in Tourette syndrome do not support the hypothesis that the condition has a significant genetic component. Methodological considerations for future research are discussed.

Unsuccessful treatment with levodopa of a parkinsonian patient with calcification of the basal ganglia

A patient aged 67 had suffered from hypoparathyroidism (tetany and cataracts) following thyroidectomy at the age of 20, although treated with AT 10. During the last few years there had been a change of gait to small steps and general retardation. Nocturnal epileptic attacks occurred in the last year which led to the admission to hospital where a well developed parkinsonian syndrome without tremor was observed. X-rays of the skull, including computed tomograms, revealed calcification of the basal ganglia and dentate nuclei. Treatment with levodopa was ineffective. The mechanism for this is discussed.

Treatment of parkinson's disease with bromocriptine

Bromocriptine in high doses (up to 100 mg per day) was administered to 14 patients with advanced Parkinson's disease whose disorder was progressing despite optimum treatment with levodopa combined with a peripheral dopa decarboxylase inhibitor (carbidopa). In 10, bromocriptine (mean dose, 57 mg) induced a statistically significant (P less than 0.01) improvement in rigidity, tremor, bradykinesia, gait disturbance and total score. In seven patients levodopa with carbidopa was completely replaced by bromocriptine (mean dose, 70 mg), with improvement in four. Adverse effects were similar to those observed with levodopa and carbidopa, except that in individual patients abnormal involuntary movements and diurnal oscillations in performance (on-off effect) were decreased whereas orthostatic hypotension and mental changes were increased. Bromocriptine appears to be a major new agent in Parkinson's disease that is especially promising in patients no longer responding to levodopa.