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Intracranial Calcification in Cone Beam CT & Medical CT
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. Cone Beam CT vs. Medical CT
CBCT Medical CT, non-contrast
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
11. 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.
12. 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
13. 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.
14. 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
16. 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.
17. 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
20. 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
23. 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
24. 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
25. Sagittal Sinus Calcification and Anatomy
Drains the blood and cerebrospinal fluid
Calcification is common in elderly
Sagittal view of sinuses Axial view of Sinuses
28. 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
29. 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
31. 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
32. 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
33. 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
34. 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
35. 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.
36. Cocckayne Syndrome
Autosomal recessive disorder, Encephalopathy, Dysmyelination
Children with Basal Ganglial Calcification
& in cerebellar and subcortical white matter regions
Basal ganglial calcification -radiopaedia.org
39. 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)
40. 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
41. 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
42. 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
43. Intracranial Tuberculosis
Protean & Affect all compartments
Associated with Tuberculous Meningitis, Tuberculous Granuloma(Tuberculoma)
CT, non-contrast - Radiopaedia.org
44. 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
46. 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
47. 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
48. 5. Hormonal & Metabolic Disorder
Fahr Disease
Parathyroid Hormone disorder
*Predominantly in Basal Ganglia and affects younger patients
61. 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
62. 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
63. 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
64. 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
65. Pineal Neoplasm: Calcification in 60-80%
Pineoblastoma: Young children, Aggressive form of tumor
Calcification is peripherally dispersed, ‘exploded’
Radiopaedia.org
66. Pineal Neoplasm
Pineocytoma: Benign with good prognosis, 20+ years of age
Well-demarcated, <3 cm
Calcification is peripherally dispersed
CT, non-contrast - Radiopaedia.org
67. 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
69. 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
70. Ganglioglioma
2% of all primary intracranial tumours
10% of primary cerebral tumours in children
Associated with Temporal lobe epilepsy
Calcified in 35% of cases
71. 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
73. 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
74. 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
76. 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
77. Metastasis of Osteogenic Sarcoma
Malignant bone forming tumour, common
CT, non-contrast, axial - Radiopaedia.org
78. 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
79. 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
80. 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
81. *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;
82. Meningeal & parenchymal calcifications likely due to
intracranial hemorrhage
Hx of motor vehicle accident and coma
Rutgers School of Dental Medicine, Oral & Maxillofacial Radiology Dept.
83. Pathologic Calcification in Basal Ganglia
Children with Cocckayne syndrome
HIV Encephalitis
Systemic Lupus Erythematosus
Fahr Disease
Parathyroid hormone disorder
Radiation therapy, mineralizing microangiopathy
85. 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
Editor's Notes
CBCT: Retrospective evaluation,
The causes for the intracranial calcifications can be organized into 7 groups.
A small endocrine gland in the vertebrate brain which produces melatonin, a serotonin derived hormone, which affects the modulation of sleep patterns in both seasonal and circadian rhythms. Physiologic calcification, typically measures around 7 x 6 x 3 mm in size, affects 2/3 of adults(1) increasingly with age but rarely seen below the age of 10 years. Pathologic calcification, possibly due to neoplasm, if the size is > 1cm in diameter or under 9 years of age.
Bilateral in atrial portions of lateral ventricles, The choroid plexus consists of modified ependymal cells. CSF is recycled (flushed) 4 times per day in order to clean out metabolites and toxins like beta amyloid
The habenula is a pair of small nuclei located above the thalamus at its posterior end close to the midline and sits just in front of the pineal body. The habenula receives inputs from the basal ganglia and the limbic system and sends outputs to midbrain and forebrain structures which contain dopaminergic and serotonergic neurons(Scholarpaedia.org). Physiologic calcification of Habenular which affects 15% of adult(1)) cannot be distinguished from Pineal gland calcification in Cone Beam CT due to lack of detail of brain tissue anatomy. In conventional CT it is visible as a small C-shaped(open part posterioly) density above and in front of the pineal calcification(Radiopaedia.org).
PL: a fold of the dura mater that extends between the anterior and posterior clinoid processes and the petrosal part of the temporal bone.
SS: allows blood to drain from the lateral aspects of anterior cerebral hemispheres to the confluence of sinuses. Cerebrospinal fluid drains through arachnoid granulations into the superior sagittal sinus and is returned to venous circulation.
The falx cerebri, also known as the cerebral falx, is a large, crescent-shaped fold of meningeal layer of dura mater that descends vertically in the longitudinal fissure between the cerebral hemispheres. Gorlin-Goltz syndrom is a rare characterised by multiple odontogenic keratocysts
association of a persistent headache with psychoneurotic symptoms
Falx Cerebri is a large, crescent-shaped fold of meningeal layer of dura mater that descends vertically in the longitudinal fissure between the cerebral hemispheres.
A collection of gray matter in cerebrum, associated with a variety of functions including: control of voluntary motor movements, procedural learning, routine behaviors or "habits" such as bruxism, eye movements, cognition,emotion.
Phakomatoses are a group of neurocutaneous disorders characterised by involvement of structures that arise from the embryonic ectoderm (thus central nervous system, skin and eyes). Other organs may also be involved.
A congenital, non-familial disorder of unknown incidence and cause. Malformation of cerebral vasculature in pia mater, venous hypertension, hypoperfusion of underlying,cortex, chronic cerebral ischemia, atrophy enlargement of ipsilateral choroid plexus & calcification.
It is characterized by a congenital facial birthmark and neurological abnormalities. eye and internal organ irregularities. Each case of Sturge-Weber Syndrome is unique and exhibits the characterizing findings to varying degrees.
Autosomal Dominant disorder, Neurocutaneous disorder(Phakomatosis), 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)
Typically appears as a mass with uniform fat density (negative HU values). It has a lobulated 'soft' appearance, conforming to adjacent anatomy. No enhancement. Some peripheral calcification may be present. -radiopaedia.org
Mutations in the NF1gene lead to the production of a nonfunctional version of neurofibromin that cannot regulate cell growth and division. an autosomal dominant pattern of inheritance, type 1 occurs in 1 in 3,000 to 4,000 people worldwide, a condition characterized by changes in skin coloring (pigmentation, cafe au lait spots <6 yr), Optic nerve glioma, Plexiform neurofibroma(30% of NF1)
The NF2 gene provides instructions for making a protein called merlin (also known as schwannomin). This protein is produced in the nervous system, particularly in Schwann cells, which surround and insulate neurons in the brain and spinal cord. Merlin acts as a tumor suppressor.Vestibular schwannomas or acoustic neuromas with symptoms of hearing loss, ringing in the ears (tinnitus), and problems with balance.
a rare autosomal recessive dysmyelinating disease, childhood leukodytrophies, Possible early Atrophy
Toxoplasma gondii: an intracellular parasite that infects birds and mammals with the cat and other Felidae species as host. Excretion of oocytes in its faecal content followed by human contaminated uncooked consumption can lead to human infection. In immunocompetent individuals, it primarily causes a subclinical or asymptomatic infection.
Rubella is one of the more teratogenic viruses. Congenital rubella syndrome (CRS) is characterized by intrauterine growth restriction, intracranial calcifications, microcephaly, cataracts, cardiac defects
Possible signs and symptoms include: jaundice/hepatomegaly/splenomegaly, microcephaly, sensorineural deafness, chorioretinitis, petechiae, mental retardation, seizures
HSV is an obligatory intracellular virus that enters via infecting nasopharyngeal cells into the sensory branch of lingual nerve then ascends to trigeminal ganglion and remains latent for a lifetime. Reactivation in the case of immunosuppression, trauma, or other stresses can result in fulminant haemorrhagic necrotizing encephalitis. HSV has a high affinity for limbic systems with bilateral but asymmetrical involvement- radiopaedial.org
. Tuberculous meningitis and intracranial tuberculous granuloma (tuberculoma) are the most common manifestations
Hydrocephalus merely denotes an increase in the volume of CSF and thus of the cerebral ventricles (ventriculomegaly).
Sarcoidosis involves the leptomeninges, granulomas of the pituitary stalk and the optic chiasm.
asymptomatic in the1st 20 years of life
Adamantinomatous in Children(90% calcified), Papillary in Adults(rarely calcified)
Low grade, good prognosis
a tumor that arises from the meninges — the membranes that surround your brain and spinal cord.
neuroepithelial intraventricular tumour, Fine, speckled calcification is seen within the tumour in approximately 25% of cases
Overall the vast majority (94%) of medulloblastomas arise in the cerebellum
malignant bone forming tumours and the second most common primary bone tumour after multiple myeloma
Dystrophy: a disorder in which an organ or tissue of the body wastes