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Neuroradiology Case of the Week

Case 59

Ravinder Sidhu MD, Ramon DeGuzman MD,
and P-L Westesson MD, PhD, DDS

Clinical Presentation: A 21-year-old male presented in an unconscious state with a gun shot injury to the abdomen.

Radiological Findings: Non-contrast enhanced head CT revealed dense hyperdense areas suggestive of calcification involving basal ganglia, thalamus, and dentate nuclei of cerebellum and gray white matter interface in the frontal lobe. Calcification was symmetrical in nature (Fig. 1A&B).

Diagnosis: Basal ganglia calcification

Discussion:  Basal ganglia calcification may be seen as an incidental finding as in the index case. Majority of basal ganglia calcification is idiopathic in nature and disturbances of calcium metabolism are so rare that biochemical testing is performed only if indicated by other features. Other causes include metabolic diseases (hypothyroidism, pseudohypothyroidism), mitochondrial cytopathy, and infectious diseases such as cytomegalovirus, Epstein-Barr virus, toxoplasmosis, tuberculosis and acquired immunodeficiency syndrome. The calcification seen in infectious diseases is usually asymmetric and not restricted to basal ganglia. Basal ganglia calcification may be seen in familial condition (Fahr’s syndrome).
    Radiologically, calcification may sometimes be observed on plain radiographs, and is frequently revealed by non-contrast computed tomography of head. However, MR imaging may show much more extensive increased signal on T1-weighted images than revealed by CT. This is believed to be due to T1 shortening in the hydration shells enclosing microscopic deposits.

References:

1. Grainger RG, Allison DJ, Adam A, Dixon AK. Cranial and intracranial pathology (3): trauma, bone pathology, CSF disturbances, degenerative disorders, and epilepsy. Diagnostic Radiology: A Text Book of Medical Imaging, Livingstone, 4th ed, vol. 3, pp 2403.
2. Morita M, Tsuge I, Matsuoka H, Ito Y, Itosu T, Yamamoto M, Morishima T. Calcification in the basal ganglia with chronic active Epstein-Barr virus infection. Neurology 1998; 50:1485-1488.