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

Fahr's syndrome due to hypoparathyroidism revisited: A case of parkinsonism and a review of all published cases

INTRODUCTION

Fahr's syndrome due to hypoparathyroidism refers to bilateral basal ganglia (BG) calcifications and manifests with movement disorders, seizures, cognitive and behavioral symptoms.

CASE PRESENTATION

We report a case of a 74-year-old woman, who presented with parkinsonism due to post-surgical hypoparathyroidism and normal DaT scan, despite extensive calcifications of the BG, periventricular white matter, and cerebellum.

METHODS

A comprehensive literature review of all reported cases of Fahr's syndrome due to hypoparathyroidism was conducted in the electronic databases PubMed and Web of science. Moreover, demographic and clinical characteristics of the patients overall were calculated and associated with radiological findings.

RESULTS

We reviewed a total of 223 cases with Fahr's syndrome due to hypoparathyroidism (124 female, 99 male). Mean age on presentation was 44.6 ± 17.7 years. Thirty nine percent of patients had idiopathic hypoparathyroidism, 35.4 % acquired and 25.6 % pseudohypoparathyroidism. Almost half of the patients had tetany, seizures or a movement disorder and approximately 40 % neuropsychiatric symptoms. The patients with a movement disorder had a 2.23 likelihood of having neuropsychiatric symptoms as well (OR 2.23, 95 % CI 1.29-3.87). Moreover, there was a statistically significant association between the phenotype severity (i.e. the presence of more than one symptom) and the extent of brain calcifications (χ² = 32.383, p = 0.009).

CONCLUSION

Fahr's syndrome is a rare disorder, which nonetheless manifests with several neurological symptoms. A head CT should be considered for patients with hypoparathyroidism and neurological symptoms. More studies using DaT scan are needed to elucidate the effects of calcifications on the dopaminergic function of the BG.

On Neuropsychiatric Manifestations of Basal Ganglia Injury: A Report of Three Cases and Literature Review

The basal ganglia have been considered to primarily play a role in motor processing. A growing body of theoretical and clinical evidence shows that in addition to the motor functions the basal ganglia play a key role in perceptual and visual disturbances. This role may be evident in patients with basal ganglia pathology and subsequent manifestation of symptoms that include cognitive, perceptual, and affective disturbances. We present three cases with basal ganglia pathology that demonstrate affective and psychotic symptoms. Two of the cases presented with late onset psychotic disturbances suggesting likely neurological etiologies. The third case presented with treatment refractory psychosis and symptoms that are rare for a diagnosis of schizophrenia. The role of incidental bilateral basal ganglia calcifications in all the cases is discussed. A review of current literature highlighting various neuropsychiatric manifestations of basal ganglia pathologies in various patients with psychiatric symptoms is presented.

Idiopathic hypoparathyroidism with extensive intracranial calcification in children: First report from Saudi Arabia

RATIONALE

Pediatric idiopathic hypoparathyroidism with extensive intracranial calcifications outside the basal ganglia (BG) is extremely rare with less than 10 cases worldwide.

PATIENT CONCERNS

An 11-year-old Saudi male child presented with tetany with otherwise normal neurological and other body system examination diagnoses severe hypocalcemia for differential diagnosis.

INTERVENTIONS

Further investigations revealed hyperphosphatemia and undetectable serum intact parathyroid hormone. Brain computed tomography revealed BG and extensive brain calcifications. He has no dysmorphic features, vitiligo, mucocuataneous manifestations, or hair loss. He had normal hemoglobin, electroencephalogram, and skeletal survey, with negative autoantibodies to alpha and omega interferons and negative genetic testing for Glial Cell Missing 2 (GCM2) and calcium-sensing receptors (CaSRs) excluding known causes of hypoparathyroidism.

OUTCOMES

This case presents a rare entity of idiopathic hypoparathyroidism with extensive intracranial calcification, not only in BG but also outside the extrapyramidal system with normal mentality, development, pubertal achievement, and neurological examination. To our knowledge, this is the first report from Saudi Arabia in pediatrics.

LESSONS

Idiopathic hypoparathyroidism is a diagnosis of exclusion after ruling out all known causes of hypoparathyroidism. It is associated with BG calcifications, but extensive intracranial calcifications outside the BG are extremely rare.

Idiopathic basal ganglia calcification presenting as schizophrenia-like psychosis and obsessive-compulsive symptoms: A case report

Idiopathic basal ganglia calcification (IBGC) is a rare neurodegenerative disorder characterized by the deposition of calcium in the brain and variable combinations of movement disorders, gait impairment and neuropsychiatric symptoms. Few reports have described psychiatric manifestations as early symptoms of IBGC. The present study reports the case of a middle-aged man with schizophrenia-like psychosis and obsessive-compulsive symptoms as the first manifestations of IBGC. The response of the patient to olanzapine and fluoxetine suggests that low-dose olanzapine is effective and should be increased cautiously to avoid worsening parkinsonism and that fluoxetine is an effective drug for the treatment of obsessive-compulsive symptoms in IBGC.

Hypoparathyroidism presenting as cognitive dysfunction

Metabolic dysfunction in hypoparathyroidism is an important cause of intracranial calcifications, which cause cognitive impairment depending on the calcified areas leading to difficulties in executing activities of daily living. We report a case of a 25-year-old man who presented with gradually decreasing organisational skills, memory problems and difficulty in carrying out daily activities. CT imaging of the brain showed extensive calcification in the basal ganglia and cerebral white matter. Comprehensive health-related quality of life and cognitive assessment revealed significant affliction in his activities of daily living along with impairment in recall memory, executive functions and verbal fluency. Owing to late diagnosis, chronicity of cognitive problems could not prevent him from discontinuing his college education.

A case report of Basal Ganglia calcification - a rare finding of hypoparathyroidism

Physiological intracranial calcification occurs in about 0.3-1.5% of cases. It is asymptomatic and detected incidentally by neuroimaging. Pathological basal ganglia calcification is due to various causes, such as: metabolic disorders, infectious and genetic diseases. Hypoparathyroidism and pseudohypoparathyroidism are the most common causes of pathological basal ganglia calcification. Besides tetany and seizures this condition is presented by parkinsonism and dementia. Such parkinsonism does not respond to drugs containing levodopa. Infections (toxoplasmosis, rubella, cytomegalovirus, cysticercosis, AIDS) give multiple and asymmetric intracranial calcification. Inherited and neurodegenerative diseases cause symmetrical, bilateral basal ganglia calcification which is not related to metabolic disorders. Since adequate treatment of hypoparathyroidism may lead to marked clinical improvement, serum concentration of calcium, phosphorus, and parathyroid hormone (PTH) is suggested to be determined in all individuals with calcification of the basal ganglia to rule out hypoparathyroidism.

Congenital hypoparathyroidism presenting as recurrent seizures in an adult

Hypocalcemia due to hypoparathyroidism may manifest as serious neurologic symptoms such as seizures, movement disorders, or raised intracranial pressure. Several patients were observed to have these dangerous neurologic complications even without subtle signs of hypocalcemia like tetany, chvostek's sign or carpopedal spasms. We present a case of recurrent hypocalcemic seizures due to congenital hypoparathyroidism.

Neurosteroid hormone vitamin D and its utility in clinical nutrition

PURPOSE OF REVIEW

Vitamin D is a seco-steroid hormone with multiple functions in the nervous system. We discuss clinical and experimental evidence of the role of vitamin D in normal and pathological brain functions, and analyze the relative importance of vitamin D-modulated brain mechanisms at different stages of life. We also outline perspectives for the use of vitamin D in clinical nutrition to prevent or treat various brain disorders.

RECENT FINDINGS

Numerous brain dysfunctions are linked to vitamin D deficits and/or dysfunctions of its receptors. In both animals and humans, vitamin D serves as an important endogenous and/or exogenous regulator of neuroprotection, antiepileptic and anticalcification effects, neuro-immunomodulation, interplay with neurotransmitters and hormones, modulation of behaviors, brain ageing, and some other, less-explored, brain processes.

SUMMARY

Vitamin D emerges as an important neurosteroid hormone in the brain, with a strong potential for age-specific applications in clinical nutrition.

Thalamic calcification in vitamin D receptor knockout mice

Vitamin D is a steroid hormone with many important functions in the brain, mediated through the nuclear vitamin D receptor. Here, we report that aging nuclear vitamin D receptor knockout mice demonstrate a symmetric thalamic calcification with numerous Ca/P-containing laminated bodies. These results are consistent with clinical findings showing brain calcification in patients with vitamin D deficiency. Our results suggest that nuclear vitamin D receptor deficiency leads to brain mineralization in vitamin D receptor knockout mice, which may represent an experimental model of intracranial calcification.

Congruence of the topography of intracranial calcifications and epileptic foci

Nodular intracranial calcifications (NIC) are frequent findings in CT scans of epileptic patients in countries where granulomatous central nervous disease such as neurocysticercosis is endemic. In 34 consecutive epileptic patients with NIC submitted to EEG, CT and CSF analysis, the correlation between the electroclinical localization of the focus and the topography of the NIC was studied. Twenty-nine patients had partial (Group I) and 5 had primarily generalized seizures (Group II). Twenty group I and 1 group II patients showed abnormal EEGs. CSF abnormalities consisted of increased protein content (n = 3) and positive Weinberg's reaction (n = 2). In 2 cases, viable neurocysticercotic vesicles were seen. Twenty-one patients had single NICs. No correlation could be established in group II patients. Within group I, 15 patients had a positive and 14 a negative correlation. Sixty-six percent of the patients with single NICs had negative correlations. These findings strongly suggest that the calcifications themselves are not the epileptogenic lesions in at least 50% of the studied cases.

Neuropsychiatric and brain CT findings in polycystic lipomembranous osteodysplasia with sclerosing leukoencephalopathy

Seven patients with polycystic lipomembranous osteodysplasia and sclerosing leukoencephalopathy (PLO-SL or membranous lipodystrophy) were examined clinically and with CT scanning. The degree of dementia was severe in five cases, marked in one case, and mild in one case. All patients suffered from marked or severe prefrontal psychosyndrome, impairment of memory and signs of upper motor neuron involvement. Epileptic seizures and primitive reflexes were observed in six cases. Degree of agnostic-aphasic-apraxic symptoms varied. In all cases CT revealed general and diffuse brain atrophy, which was accentuated in frontal areas. In the basal ganglia bilateral calcifications (five cases) or a slight hyperdensity (two cases) were detected. CT finding in PLO-SL may lead to an early diagnosis of this fatal disease.

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.

Basal ganglia calcifications in postoperative hypoparathyroidism: a case with unusual characteristics

A patient is described with post-thyroidectomy hypoparathyroidism and basal ganglia calcifications. The patient presented with a tonic-clonic seizure. The calcifications shown on CT scan were extensive in the basal ganglia, the bifrontal periventricular white matter and even in the brainstem. The white matter with calcifications displayed a high signal intensity on MRI, probably due to a different stage of the calcifying process in the white matter than in the basal ganglia. A severe dystonic reaction was observed after phenothiazine therapy and is discussed.

The high rate of prevalence of CT-detected basal ganglia calcification in neuropsychiatric (CNS) brucellosis

Of 65 cases presenting with neuropsychiatric manifestations of brucellosis (CNS-brucellosis), 9(13.8%) had CT-detected basal ganglia calcification (BGC). Of these, 5 had meningitis and 4 had psychiatric manifestations as presenting features. The diagnosis of brucellosis was made by the finding of consistent history and physical findings and the presence of significantly elevated antibody titres and/or positive culture in the blood and/or CSF. In all the cases, BGC was in the form of punctate hyperdense non-enhancing shadows with average density 44.5-58.4 and maximum density 49-64HU. The calcification was unilateral in 3 cases, bilateral and symmetrical in 4 and bilateral but asymmetrical in 2. None of the cases had other predisposing conditions to BGC and in one of the cases did specific anti-brucella treatment effect a detectable change in the BGC. The finding of CT-detected BGC in patients coming from areas endemic for brucellosis should alert physicians to the possibility of underlying brucellar infection.

Dystrophic intracranial calcification: CT evidence of 'cerebral steal' from arteriovenous malformation

Two cases of dystrophic intracranial calcification due to arteriovenous malformations (AVM) are reported. The characteristic distribution is in the watershed areas and away from the AVM. Deposition of calcium on ischaemic brain tissues as a result of 'cerebral steal' by the AVM is the probable pathogenetic mechanism.