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Intracranial Calcification in Cone Beam CT & Medical CT

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Review of calcification in the brain observed in Cone Beam CT & Medical CT

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Intracranial Calcification in Cone Beam CT & Medical CT

  1. 1. Intracranial Calcification in Cone Beam CT & Medical CT Judy H. Oh, D.D.S. UCLA School of Dentistry, 1992 Preceptorship for Oral & Maxillofacial Radiology at Rutgers School of Dental Medicine 3D Oral & Maxillofacial Imaging Center, N. Bethesda, MD 3DOMI.net
  2. 2. Cone Beam CT vs. Medical CT CBCT Medical CT, non-contrast
  3. 3. Effective Dose & Risk 100 mSv/year: Lowest level for cancer risk 10-12 mSv: CT scan of abdomen/pelvis, angiography 9 mSv: Flight from NY to Tokyo 2-4 mSv: CT scan of head 2-3 mSv: Background radiation per year 0.4 mSv: Mammography 0.2 mSv: Chest x-ray 0.13 mSv: CBCT mandibular molar(80kV, 9mA) 0.024 mSv: CBCT maxillary molars/incisors(80kV, 6mA) 0.01mSv: Dental x-ray Reference: radiologyinfo.org 3DOMI.net
  4. 4. Axial, Coronal, Sagittal 3DOMI.net A S C
  5. 5. What is this radiopaque ‘grain-like’ in the middle of the brain? CBCT
  6. 6. CBCT
  7. 7. CBCT
  8. 8. CT, non-contrast
  9. 9. CT, non-contrast
  10. 10. Review of medical CT scans by Dr. Daghighi 1569 CT scans reviewed in 2007: Tabriz, Iran Subjects: 15 - 85 years age with Hx of head trauma Calcification: male > female Increased at older ages, except for lens & non-defined structures 71% in Pineal Gland 66% in Choroid Plexus 20% in Habenular Commissure 7.3% in Tentorium Cerebelli, Sagittal Sinus or Falx Cerebri 6.6% in Vascular 0.8% in Basal Ganglia 0.9% in Lens, non-defined structures MH Daghighi, et al. Intracranial physiological calcifications in adults on computed tomography in Tabriz, Iran. Folia Morphol (Warsz). 2007 May;66(2):115-9.
  11. 11. 176/500 subjects with physiologic calcifications(35.2%), 2012: USC School of Dentistry 176 subjects: 13 - 82 years age (mean 52 years) 3:2 = male:female no ethnic predilection Calcification: 80% in Pineal Gland/Habenular 12% in Choroid Plexus region(bilateral) 8% in Petroclinoid Ligament(bilateral) None with pathological calcification PP Sedghizadeh, et al. Intracranial physiological calcifications evaluated with cone beam CT. Dentomaxillofacial Radiology (2012) 41, 675–678 ’ 2012 The British Institute of Radiology Review of CBCT scans by Dr. Sedghizadeh
  12. 12. Discussion: Dr. P.P. Sedghizadeh Consistent findings in CBCT with previous study of CT scans: Pineal gland being the most common male > female pathology is uncommon Yet, frequency is lower in his study: CT - higher tube current, better soft tissue contrast & less noise. CT - the imaging modality of choice in detecting intracranial calcification.
  13. 13. Pathological vs. Physiological Intracranial Calcification Pathological Larger than a few mm Abnormal in shape & configuration Non-symmetrical Irregular borders Uncommon location Physiological Small Well-defined borders Symmetrical to midline or Bilateral Reference: PP Sedghizadeh, et al. Intracranial physiological calcifications evaluated with cone beam CT. Dentomaxillofacial Radiology (2012) 41, 675– 678 ’2012 The British Institute of Radiology
  14. 14. Causes of Intracranial Calcifications by Dr. Y. Kiroglu, 2010 1. Age-related, Physiologic & Neurodegenerative 2. Congenital 3. Infectious 4. Inflammatory* 5. Hormonal & Metabolic 6. Vascular 7. Neoplastic Yılmaz Kıroğlu, Cem Çallı, Nevzat Karabulut, Çağatay Öncel. Intracranial calcifications on CT. Diagn Interv Radiol 2010; 16:263– 269 © Turkish Society of Radiology 2010 *Erini Makariou, MD, and Athos D. Patsalides, MD, Applied Radiology; Intracranial calcifications
  15. 15. 1. Age-Related, Physiologic & Neurodegenerative Most Common Sites: Pineal Gland: ⅔ of adults Choroid Plexus: very common in >40 yr old Habenula: 15% of adults, can’t be distinguished from Pineal in CBCT Petroclinoid Ligaments, Sagittal Sinus: common in elderly Falx Cerebri, Dura Mater, Tentorium Cerebelli: 10% of elderly Basal Ganglia*: 0.3 - 1.5% incidence increases with aging Reference: Kiroglu, Yilmaz et al. "Intracranial calcifications on CT." Diagnostic and Interventional Radiology 16.4 (2010): 263.
  16. 16. Pineal Gland Calcification and Anatomy Endocrine gland: Melatonin 7x6x3mm in size, ‘pine nut’ 2/3 of Adults, Age related, rarely seen in children Possible Neoplasm if >1 cm in diameter or under 9 years of age
  17. 17. Pineal Gland Calcification in CBCT
  18. 18. Pineal Gland Calcification in CBCT
  19. 19. Choroid Plexus Calcification and Anatomy Produces the cerebrospinal fluid in the ventricles of the brain Common in >40 years, 66% occurrence, bilateral in lateral ventricles Uncommon in 3rd & 4th ventricle or in <9 years
  20. 20. Choroid Plexus Calcification Pineal Gland(and/or Habenular) Calcification Reference: Radiopaedia.org & Dr. Balaji Anvekar’s Radiology cases
  21. 21. Choroid Plexus Calcification & Anatomy cont’d
  22. 22. Habenular Commissure Calcification and Anatomy A pair of small nuclei, above the thalamus close to the midline 15% of adults, observed in CT near the Pineal gland
  23. 23. Petroclinoid ligament Calcifications & Anatomy Petroclinoid ligament calcification Dura Mater fold between the clinoid processes & the petrosal part of the temporal bone Anterior Petroclinoid Ligament Posterior Petroclinoid Ligament Atherosclerosis in Internal Carotid Artery
  24. 24. Sagittal Sinus Calcification and Anatomy Drains the blood and cerebrospinal fluid Calcification is common in elderly Sagittal view of sinuses Axial view of Sinuses
  25. 25. Falx Cerebri, Tentorium Cerebelli, Dura Mater Calcification 10% of population, mostly elderly Pathologic calcification: Nevoid basal cell carcinoma syndrome(Gorlin-Goltz) Chavany-Brunhes syndrome(psychoneurotic symptom, persistent headache) Falx Cerebri calcification Tentorium Cerebelli calcification Radiopaedia.org Dural Calcification
  26. 26. Anatomy
  27. 27. Basal Ganglia Calcifications and Anatomy A collection of gray matter in cerebrum, controls voluntary motor movements or ‘habit’ such as bruxism 0.3- 1.5% incidence, Related to aging, Pathology likely if found < 40 years of age Bilateral and Symmetrical pattern Radiopaedia.org
  28. 28. Orbits 1. Bony Variations: Displacement of Lamina Papyracea Discontinuity of medial bony border Caused by Trauma, Iatrogenic, or Congenital Indicated for Referral 2. Calcifications: Scleral plaques: Age related, Linear or curved, Small masses At insertion sites of medial & lateral rectus muscles; Medial from the convexity of globe Calcification on the Globe: Macular degeneration, Infection, Inflammation or Trauma Shawneen Gonzalez, DDS, MS, Interpretation Basics of CBCT, Chapter 6
  29. 29. 2. Congenital(Phakomatoses) Disorders Sturge-Weber Syndrome Tuberous Sclerosis Intracranial Lipoma Rare: Neurofibromatosis type 1 & 2 Cocckayne Syndrome Gorlin Syndrome
  30. 30. Sturge-Weber Syndrome and Calcification Malformation of cerebral vasculature, cerebral ischemia, venous hypertension Characterised by facial birthmark & neurological abnormalities ‘rail road track’ Engorged choroid plexus (white arrow) related to angiomatosis Contrast-enhancement of pial vessels(yellow arrow) Gyral calcifications (red arrow) Reference: Neuroradiology, Pitié-Salpêtrière - Paris/FR
  31. 31. Tuberous Sclerosis Neurocutaneous, Autosomal dominant disorder Multiple benign tumors of embryonic ectoderm(skin, eyes, nervous system) Mental retardation, Seizures, Adenoma sebaceum Calcification is common in subependymal hamartomas *Subependymal: under the lining of the ventricles *Hamartomas: benign tumour-like malformation made up of abnormal mixture of cells and tissues belong in the area
  32. 32. Intracranial Lipoma Benign, Asymptomatic, Incidental findings Density of Fat, some with Peripheral Calcifications Reference: Ozlem Bilir, MD, Incidental Finding in a Headache Patient: Intracranial Lipoma, West J Emerg Med. 2014 Jul; 15(4): 361–362 CT image MRI image MRI image
  33. 33. Neurofibromatosis(NF1), von Recklinghausen disease Mutation in NF1 gene, Production of nonfunctional, uncontrolled growth of Neurofibromin Changes in Skin Coloring(pigmentation, cafe au lait spots <6yr) Optic Nerve Glioma, Plexiform Neurofibroma Optic Nerve Glioma in NF1- eyerounds.org optic glioma radiology humanbodyanatomyedu.com MRI, radiopaedia.org Plexiform neurofibroma of the left neck, a benign tumor of peripheral nerves. risk of malignant transformation in 5-10% of cases
  34. 34. Neurofibromatosis type 2 Autosomal Dominant: Mutation of NF2 gene which regulates Merlin(Schwannomin) protein production Appear during adolescence or early twenties Symptoms of hearing loss, ringing in the ears (tinnitus), and problems with balance. CT: (a,c) multiple small calcifications along falx, right tentorium, basal cistern (white arrows), (b) subependymal locations along with bilateral choroid plexus calcifications (d) peripheral curvilinear calcification along optic nerve Reference: Senthil Kumar Aiyappan, Upasana Ranga, and Saveetha Veeraiyan, Neurofibromatosis type 2: Intracranial calcifications as a clue to diagnosis, J Neurosci Rural Pract. 2015 Jan-Mar; 6(1): 120–121.
  35. 35. Cocckayne Syndrome Autosomal recessive disorder, Encephalopathy, Dysmyelination Children with Basal Ganglial Calcification & in cerebellar and subcortical white matter regions Basal ganglial calcification -radiopaedia.org
  36. 36. Gorlin-Goltz Syndrome Autosomal Dominant tumor: Rare Multiple Basal Cell Carcinomas of Skin, Odontogenic Keratocyst of jaw, Skeletal Abnormality Lamella Falx Calcification Gorlin-Goltz syndrome-sagittal, radiopaedia.org Gorlin-Goltz syndrome-coronal, radiopaedia.org Odontogenic Keratocyst - radiopaedia.org
  37. 37. 3. Infectious Disorder causing Intracranial Calcifications “TORCH’: Cause congenital defects Toxoplasmosis Rubella Cytomegalo Virus Herpes Simplex Intracranial Tuberculosis & other Fungal infections
  38. 38. Toxoplasmosis Toxoplasma gondii parasite, one of the world's most common parasites. Typically affects patients with HIV/AIDS causing Cerebral Abscess Calcification in treated cases, appears dot-like or thick and 'chunky' - radiopaedia.org Subclinical congenital toxoplasmosis: asymptomatic at birth, later develop neurologic, intellectual & audiologic deficits A characteristic imaging finding of toxoplasmosis: "asymmetric target sign:" Typically, any abscess forms a ring-enhancing lesion; however, in toxoplasmosis, there is an enhancing, eccentrically situated nodule within this ring. (courtesy of Dr. P. Harrison, Vancouver, Israradiology.org)
  39. 39. Rubella(German measles, 3-day measles) CT scan: hydrocephalus and periventricular calcification, suggestive of toxoplasmosis, other agents, rubella, cytomegalovirus, herpes simplex (TORCH) infection.-(Coutesy of Erik Hagen, M.D., peds.umn.edu/neonatology) Togavirus, Transmission by Transplacental & Respiratory secretions “Blueberry Muffin” rash due to extramedullary hematopoiesis
  40. 40. Cytomegalo Virus(CMV) CMV: a DNA virus in the herpes virus family The most common cause of intra-uterine infection The most common cause of congenital infective, brain damage Intracranial Calcifications: periventricular regions with faint, punctate basal ganglia calcifications
  41. 41. Herpes Simplex Virus Childhood and adult herpes encephalitis is usually due to HSV-1 (90%) with the rest due to HSV-2 Hemorrhagic Necrotizing Encephalitis High affinity for Limbic system: Bilateral but Asymmetrical MRI, T2, radiopaedia.org HSV Encephalitis
  42. 42. Intracranial Tuberculosis Protean & Affect all compartments Associated with Tuberculous Meningitis, Tuberculous Granuloma(Tuberculoma) CT, non-contrast - Radiopaedia.org
  43. 43. CNS Cryptococcosis Yeast like Fungus Cryptococcus neoformans The most common fungal infection The second most common opportunistic infection of the CNS Affects HIV/AIDS patients & Immunocompromised patients(close contact with birds) Calcification in brain Parenchyma & Leptomeninges Diffuse Atrophy & Hydrocephalus HIV Encephalitis Associated with pathological Basal Ganglia Calcifications Reference: Radiopaedia.org
  44. 44. 4. Inflammatory Intracranial Calcifications Sarcoidosis Systemic Lupus Erythematosus Reference: Erini Makariou, MD, and Athos D. Patsalides, MD, Applied Radiology; Intracranial calcifications
  45. 45. Sarcoidosis Disorder of Immune regulation, unknown etiology Typically affecting patients 30-40 years of age with a female predilection Presence of widespread Granulomas CNS involvement in 14-27% of patients with systemic sarcoidosis Leptomeningeal(seen in up to 40% of cases): pituitary, hypothalamic, cranial nerve Parenchymal involvement (most common) Reference: Radiopaedia.org Osteolysis of the ethmoid sinus wall, bilateral emedicine.medscape.com/ article/345765
  46. 46. Systemic Lupus Erythematosus Autoimmune disease or called vasculitis Predilection for female, 20-40 years of age Affects multisystem, about 45% manifests in CNS Calcification in Basal Ganglia, Thalamus, Cerebellum, Centrum Semiovale Reference: R.H. Andres, et al, J Neurol Neurosurg Psychiatry 2008;79:365 doi:10.1136/jnnp.2007.125393
  47. 47. 5. Hormonal & Metabolic Disorder Fahr Disease Parathyroid Hormone disorder *Predominantly in Basal Ganglia and affects younger patients
  48. 48. Fahr Disease Rare degenerative, neurological disorder Defective iron transport causing tissue damage & calcification Bilateral Basal Ganglia Calcification Dystonia, Parkinsonism, Neuropsychiatric manifestation CT, non-contrast - Radiopaedia.org
  49. 49. Parathyroid hormone The hormone maintains the plasma calcium. Any hormonal imbalance(hypo, hyper, pseudohypo) leads to intracranial calcification Bilateral Basal Ganglia(most common), subcortical white matter, corona radiata and thalamus Pseudohypoparathyroidism CT - Radiopaedia.org
  50. 50. 6. Vascular Disorder causing Intracranial Calcification: 6.6% incidence according to Dr. Daghighi’s study Atherosclerosis in elderly causes intracranial artery calcification. Internal Carotid Artery: 60% Vertebral Artery: 20% Middle Cerebral Artery: 5% Basilar Artery: 5% *Notify patient’s physician!
  51. 51. Internal Carotid Artery & Cavernous sinus: sagittal view
  52. 52. Internal Carotid Artery in the Cavernous sinus: axial view
  53. 53. Circle of Willis
  54. 54. Network of Arteries: coronal view
  55. 55. Calcification in the Internal Carotid Arteries Reference: Dr Bruno Di Muzio - Radiopaedia.org
  56. 56. Internal Carotid Artery Calcification CBCT E. Benavides, DDS, Ph.D, P. Edwards, MSc, DDS, Detection of Incidental Findings in CBCT Imaging & Their Clinical Implications, Chapter 10, Pocket Dentistry
  57. 57. Calcifications in the arteries of the brain R/L Internal Carotid Artery Right Anterior Cerebral Artery R/L Vertebral Artery Non-contrast CT J Clin Neurol. 2016 Jan;12:e23. Copyright © 2016 Korean Neurological Association
  58. 58. Other Vascular related Intracranial Calcification Aneurysm Mural calcification, partially or completely Arteriovenous Malformation Dystrophic calcification along serpentine vessels, adjacent parenchyma Cavernous Malformation Benign vascular hamartoma, Popcorn-ball fashion
  59. 59. Aneurysm, Arteriovenous, Cavernous Malformation Intracranial artery calcification in aneurysm Arteriovenous Malformation Cavernous Malformation
  60. 60. 7. Neoplastic Intracranial Calcification(in the order of frequency) Oligodendroglioma Craniopharyngioma Germ Cell Neoplasms Pineal Neoplasms: Pineoblastoma, Pineocytoma Central neurocytoma Primitive Neuroectodermal Tumor(PNET) Ependymoma Ganglioglioma Dysembryonic Neuroectodermal Tumor(DNET) Meningioma(dural based in elderly, variable pattern) Choroid Plexus Papilloma Medulloblastoma Rare in: Astrocytoma, Schwannomas, Dermoid/Epidermoid tumors Metastases except Osteogenic Sarcoma, Mucinous Adenocarcinoma, Radiotherapy, Chemotherapy
  61. 61. Oligodendroglioma 5-10% of all primary intracranial neoplasms, 70-90% Calcified Affects middle-aged adults Well-circumscribed, commonly in Frontal lobe(nodular, clumped pattern) CT, non-contrast - Radiopaedia.org
  62. 62. Craniopharyngioma 1-5% of primary brain tumours in the Sellar/Suprasellar region 90% calcified in children, rarely calcified in adults Amorphous & Lobulated pattern CT, non-contrast - Radiopaedia.org
  63. 63. Intracranial Germ Cell Neoplasm 0.4 to 1% of brain tumours, 8x higher incidence in Far East Peak at 10-19 years of age 60-80% Calcified, mostly in Pineal, Suprasellar regions Pineal, CT, non-contrast Pineal, MRI Radiopaedia.org
  64. 64. Pineal Neoplasm: Calcification in 60-80% Pineoblastoma: Young children, Aggressive form of tumor Calcification is peripherally dispersed, ‘exploded’ Radiopaedia.org
  65. 65. Pineal Neoplasm Pineocytoma: Benign with good prognosis, 20+ years of age Well-demarcated, <3 cm Calcification is peripherally dispersed CT, non-contrast - Radiopaedia.org
  66. 66. Central Neurocytoma 0.25-0.5% of intracranial tumours, 20-40 years of age Located within the ventricles Calcification in >50%, Punctate in nature sumerdoc.blogspot.com
  67. 67. Primitive Neuroectodermal Tumor(PNET) Aggressive, <10 years of age Calcification in 50-70% Supratentorial PNET CT - Radiopaedia.org
  68. 68. Ependymoma Differentiated ependymal cells lining the ventricles of the brain 10% of all paediatric brain tumours, up to 33% of brain tumours for < 3 years of age Calcification in 50% of cases, Coarse Ependymoma in Lateral Ventricle CT, non-contrast - Radiopaedia.org
  69. 69. Ganglioglioma 2% of all primary intracranial tumours 10% of primary cerebral tumours in children Associated with Temporal lobe epilepsy Calcified in 35% of cases
  70. 70. Dysembryonic Neuroectodermal Tumor(DNET) Benign, slow growing tumour in children or young adults Affects the temporal lobe, frontal lobe, causes seizures Calcification in 30% of cases MRI - Radiopaedia.org
  71. 71. Meningioma Benign, rarely malignant, tumour of meninges Calcification in 20-30% of cases CT - Radiopaedia.org
  72. 72. Choroid Plexus Papilloma Benign, 1% of all brain tumour More common in children(85% in <5 years of age) Well-defined lobulated masses, cauliflower-like appearance Calcification in 25% of cases(fine, speckled) Radiopaedia.org CT axial C+ CT sagittal non-contrast
  73. 73. Medulloblastoma Most common malignant brain tumour of childhood Majority located in the cerebellum Calcification seen in 10-20% of cases CT, non-contrast - Radiopaedia.org
  74. 74. Intracranial Calcification is rare, <10% Low Grade Astrocytoma Pilocytic Astrocytoma Schwannomas, Dermoid Epidermoid Tumors
  75. 75. Pituitary Gland Tumors If > 9mm in vertical dimension, thinning & sloping of floor of sella turcica, extend into sphenoid sinus Calcification occurs rarely. E. Benavides, DDS, Ph.D, P. Edwards, MSc, DDS, Detection of Incidental Findings in CBCT Imaging & Their Clinical Implications, Chapter 10, Pocket Dentistry
  76. 76. Metastasis of Osteogenic Sarcoma Malignant bone forming tumour, common CT, non-contrast, axial - Radiopaedia.org
  77. 77. Metastasis 80% of brain metastasis can be accounted for by five primary tumours 1. Lung cancer 2. Renal Cell carcinoma 3. Breast cancer 4. Melanoma 5. Gastrointestinal tract adenocarcinomas, the majority colorectal carcinoma Lung cancer, CT, non-contrast Breast cancer, CT, non-contrast Melanoma, CT, non-contrast
  78. 78. Radiotherapy, Chemotherapy • mineralizing microangiopathy: affects small arteries and arterioles, resulting in basal ganglia and subcortical white-matter calcifications; mostly due to radiation therapy; intracerebral calcification mostly seen in children • necrotizing leukoencephalopathy: results in white-matter calcifications in the posterior hemisphere • dystrophic brain calcifications Reference: Erini Makariou, MD, and Athos D. Patsalides, MD, Applied Radiology; Intracranial calcifications; Radiopaedia.org
  79. 79. Teratoma - uncommon in the general population Germ cell tumours, 26-50% of fetal brain tumours Some fat and some calcification, usually solid / "clump-like", irregular outline. Mature teratoma of the lateral ventricle in adulthood: Axial noncontrast CT scan showing a fat component (large arrows) and several small calcifications (small arrows) in this right lateral ventricular tumor. - Journal of the American Academy of Neurology
  80. 80. *Dystrophic Calcifications Caused by trauma, surgery, ischemia and radiation therapy Post traumatic calcifications have been described in the capsule surrounding both chronic subdural and epidural hematomas. Reference: Erini Makariou, MD, and Athos D. Patsalides, MD, Applied Radiology; Intracranial calcifications;
  81. 81. Meningeal & parenchymal calcifications likely due to intracranial hemorrhage Hx of motor vehicle accident and coma Rutgers School of Dental Medicine, Oral & Maxillofacial Radiology Dept.
  82. 82. Pathologic Calcification in Basal Ganglia Children with Cocckayne syndrome HIV Encephalitis Systemic Lupus Erythematosus Fahr Disease Parathyroid hormone disorder Radiation therapy, mineralizing microangiopathy
  83. 83. References Images: 1. Radiopaedia.org 2. Ozlem Bilir, MD, Incidental Finding in a Headache Patient: Intracranial Lipoma, West J Emerg Med. 2014 Jul; 15(4): 361–362 3. E. Benavides, DDS, Ph.D, P. Edwards, MSc, DDS, Detection of Incidental Findings in CBCT Imaging & Their Clinical Implications, Chapter 10, Pocket Dentistry Articles: 1. Yılmaz Kıroğlu, Cem Çallı, Nevzat Karabulut, Çağatay Öncel. Intracranial calcifications on CT. Diagn Interv Radiol 2010; 16:263–269 © Turkish Society of Radiology 2010 2. Daghighi MH1, Rezaei V, Zarrintan S, Pourfathi H. Intracranial physiological calcifications in adults on computed tomography in Tabriz, Iran. Folia Morphol(Warsz). 2007 May;66(2):115-9 3. PP Sedghizadeh*, M Nguyen and R Enciso. Intracranial physiological calcifications evaluated with cone beam CT. Dentomaxillofacial Radiology (2012) 41, 675–678 ’ 2012 The British Institute of Radiology 4. Dale A. Miles BA, DDS, MS, FRCD(C) Diplomate, ABOM; Diplomate, ABOMR. Interpreting the CBCT Data Volume in Orthodontic Cases: "You Should See What You May Be Missing"!. learndigital.net/articles/2012/Assessment-CBCT-Data- Volume-Orthodontic-Cases 5. Erini Makariou, MD, and Athos D. Patsalides, MD, Applied Radiology; Intracranial calcifications
  84. 84. with gratitude for your generous support! Dr. S. Singer Dr. A. Creanga Dr. M. Strickland Dr. A. Abbas Dr. Zia Haris & Dr. AlSakr Abdulaziz Oral & Maxillofacial Radiology Department Rutgers School of Dental Medicine

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