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Cerebellar calcification on computerized tomography.

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7. Ludden TM, Allen JR, et al: Individualization of phenytoin
dosage regimens. Clin Pharmacol Ther 2 1:287-293, 1977
8. Lund L: Anticonvulsant effect of diphenylhydantoin relative
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5:579-596, 1977
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Cerebellar Calcification
on Computerized
Tomography
William C. Koller, MD, PhD, and Harold L. Klawans, MD
Cerebellar calcification on C T scan was observed in
five patients over a two-year period. It was located
bilaterally and symmetrically in the dentate nucleus in
all 5 patients and in the cerebellar vermis in one.
Calcifications of the basal ganglia and cerebral cortex
were associated in two cases each. Skull radiography
did not reveal the cerebellar calcifications, and serum
calcium levels were normal in all patients. None had
symptoms or signs of cerebellar dysfunction, and they
had a variety of different clinical diagnoses. Cerebellar
calcification may be a form of benign intracerebral
calcification.
Koller WC, Klawans HL: Cerebellar calcification
on computerized tomography. Ann Neurol
7:193-194, 1980
Intracerebral calcifications occur in a variety of pathological and physiological conditions, including
tuberous sclerosis, Sturge-Weber syndrome, perinatal toxoplasmosis, rubella, cytomegalic inclusion
disease, tumors, abscesses, aneurysms, and hematomas. Physiological or benign calcifications constitute calcium deposits not involving a pathological process. W e report 5 patients with cerebellar
calcifications detected by C T scan and suggest that
they also may represent a physiological form of
calcification.
From the Department of Neurological Sciences, RushPresbyterian-St. Luke's Medical Center, 1725 W Harrison St,
Chicago, IL 60612.
Accepted for publication July 28, 1979.
Address reprint requests to Dr Koller, 1725 W Harrison St,
Chicago, IL 60612.
Methods and Results
Over a two-year period, all CT scans at RushPresbyterian-St. Luke's Medical Center were reviewed for
cerebellar calcifications. Patients with this finding were
interviewed and examined. Skull roentgenograms and
serum calcium, inorganic phosphorus, and alkaline phosphatase levels were obtained in all patients. Serum
parathyroid hormone was measured when the serum calcium was at the lower limits of normal.
The radiographic and clinical characteristics of five patients with cerebellar calcifications on CT scan are summarized in the Table. There were four women and one man
with an average age of 66.4 years. The calcifications were
bilaterally and symmetrically located in the dentate nucleus
in all cases, and in one patient the vermis was also calcified.
The calcifications in the dentate nucleus tended to vary in
size from patient to patient and were generally large. Bilateral globus pallidus and bilateral cerebral cortex calcifications were associated findings in two patients each. One of
these patients had calcifications of both the basal ganglia
and cortex which were particularly extensive (Figure). In
two of the patients only the cerebellum was calcified. Skull
radiography did not demonstrate the cerebellar calcification in any of the 5 patients, but in one it revealed unilateral cortical calcification. N o patient was found to have
abnormal serum calcium, phosphorus, or parathyroid hormone levels. No patient had symptoms or signs of cerebellar dysfunction or a history of perinatal disease or prior
neurological difficulties. Family histories were negative for
neurological disease.
Discussion
Cerebellar calcification has been reported previously
as a rare finding o n skull radiography [1-3]. C T appears to be a more sensitive method for its detection. Likewise, C T scan demonstrates basal ganglia
calcification when skull radiography is normal [4, 61.
Cerebellar calcifications o n skull roentgenograms
have been reported to be bilateral [ 1-31; however,
exact radiographic localization was not possible before CT. Neuropathological studies confirm the
dentate nucleus as the primary site of cerebellar
calcification [3, 71.
I t had previously been thought that a large percentage of cases of cerebellar and basal ganglia
calcification found by skull radiographs were caused
by underlying disorders of calcium metabolism [ 5 ]
such as idiopathic and postoperative hypoparathyroidism and pseudohypoparathyroidism. Recent studies of basal ganglia calcification o n C T have failed
to document disturbances of calcium-phosphorus
metabolism [4, 61 and suggest that basal ganglia
calcification o n C T scan is usually idiopathic. Similarly, in this study n o abnormalities of serum calcium
chemistries were found. While the association of
cerebellar calcification with hypoparathyroidism appears well documented, this study indicates that most
such patients are euparathyroid.
0364-5134/S0/020193-02$01.25 @ 1979 by William C . Koller
193
Cliiiil-adlarid Radiiugrtzphii. Characteri.stirs of 5 Paticnts with Cerebellar Cakcifirations
Patient No.,
Sex, and
Age (yr)
1. F, 89
2. F, 72
3. M, 54
4.F, 59
Location of
Calcification
Associated
Calcification
Bilateral dentate
nucleus
Bilateral dentate
nucleus
Bilateral globus
pallidus
Bilateral globus
pallidus; bilateral
cerebral cortex
Bilateral cerebral
cortex
None
None
Bilateral dentate
nucleus; verrnis
Bilateral dentate
Skull
Roentgenogram
Calcium
Metabolism
Cerebellar
Symptoms
or Signs
Final
Diagnosis
Normal
Normal
Absent
Hypoglycemia
Unilateral cortical ca1cifica.tion
Normal
Normal
Absent
Depression
Normal
Absent
Normal
Normal
Absent
Normal
Normal
Absent
Tension headache
Peripheral neuropathy
Vertebrobasiliar
insufficiency
nuc.leus
5. F, 58
Bilateral dentate
nucleus
In the present investigation, no patient had symptoms or signs of cerebellar disease. Likewise, in two
patients with bilateral cerebellar calcification on skull
roentgenograms reported by King and Goulci [ 3 ] ,the
calcifications were thought to have no direct bearing
on symptoms o r physical findings. Calcification of the
dentrate nucleus can be observed microscopically in
40 to 70% o f routine autopsies, and despite excessive mineral deposits, there is seldom any appreciable
loss of nerve cells o r myelin [8, 91. If cerebellar
calcification is not involved in a pathological process,
it too should be classified as physiological calcification.
References
3. King AB, Gould DM: Symmetrical calcification in the cerebellum. Am J Roentgenol 67:562-568, 1952
4 . Koller WC, Cochran J , Klawans HL Basal ganglia calcification:
5.
6.
7.
1. Camp JD: Symmetrical calcification of the cerebral basal ganglia; its roentgenologic significance in the diagnosis of
parathyroid deficiency. Radiology 49:508-599, 1942
2. Foley J: Calcification of the corpus striatum and dentate nuclei
occurring in a family. 1 Neurol Neurosurg Psychiatry 14:
253-261, 1951
194 Annals o t Veurologk
Bilateral cak-ifli.atioizsin the dentate tiudeu~(A),
basal Ranglia ( B ) .aizd i-erebraltartrx ( C , in Pati~nt2 .
Vol
7
No 2
February 1980
8.
9.
computerized tomography and clinical correlation. Neurology
(Minneap) 29:328-333, 1979
Muenter M D , Whisnant TP: Basal ganglia calcifications, hypoparathyroidism, and extrapyramidal motor manifestations.
Neurology (Minneap) 18:1075-1083, 1968
Murphy MJ, Cornell SH, Van Allen MW: Basal ganglia
calcification: detection by computerized tomography of the
head. Ann Ncurol 4:171, 1978
Neumarin MA: Iron and calcium dysmetabolism in the brain. J
Neuropathol Exp Neurol 22:148-163, 1963
Slager UT, Wagner JA: The incidence, composition, and pathological significance of intracerebral vascular deposits in the
basal ganglia. J Neuropathol Exp Neurol 15:417-/13 1, 1956
Strassman G: Iron and calcium deposits in the brain. J
Neuropathol Exp Neurol 8:428-435, 1949
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cerebellar, computerized, calcification, tomography
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