Review of calcification in the brain observed 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

4. Axial, Coronal, Sagittal
3DOMI.net
A S
C

5. What is this radiopaque ‘grain-like’ in the middle of the brain?
CBCT

6. CBCT

7. CBCT

8. CT, non-contrast

9. CT, non-contrast

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

15. 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

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

18. Pineal Gland Calcification in CBCT

19. Pineal Gland Calcification in CBCT

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

21. Choroid Plexus Calcification Pineal Gland(and/or Habenular) Calcification
Reference: Radiopaedia.org & Dr. Balaji Anvekar’s Radiology cases

22. Choroid Plexus Calcification & Anatomy cont’d

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

26. 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

27. Anatomy

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

30. 2. Congenital(Phakomatoses) Disorders
Sturge-Weber Syndrome
Tuberous Sclerosis
Intracranial Lipoma
Rare: Neurofibromatosis type 1 & 2
Cocckayne Syndrome
Gorlin Syndrome

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

37. 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

38. 3. Infectious Disorder causing Intracranial Calcifications
“TORCH’: Cause congenital defects
Toxoplasmosis
Rubella
Cytomegalo Virus
Herpes Simplex
Intracranial Tuberculosis & other Fungal infections

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

45. 4. Inflammatory Intracranial Calcifications
Sarcoidosis
Systemic Lupus Erythematosus
Reference: Erini Makariou, MD, and Athos D. Patsalides, MD, Applied Radiology; Intracranial calcifications

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

49. 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

50. 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

51. 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!

52. Internal Carotid Artery & Cavernous sinus: sagittal view

53. Internal Carotid Artery in the Cavernous sinus: axial view

54. Circle of Willis

55. Network of Arteries:
coronal view

56. Calcification in the Internal Carotid Arteries
Reference: Dr Bruno Di Muzio - Radiopaedia.org

57. 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

58. 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

59. 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

60. Aneurysm, Arteriovenous, Cavernous Malformation
Intracranial artery calcification in aneurysm Arteriovenous Malformation Cavernous Malformation

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

68. Primitive Neuroectodermal Tumor(PNET)
Aggressive, <10 years of age
Calcification in 50-70%
Supratentorial PNET
CT - Radiopaedia.org

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

72. Meningioma
Benign, rarely malignant, tumour of meninges
Calcification in 20-30% of cases
CT - 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

75. Intracranial Calcification is rare, <10%
Low Grade Astrocytoma
Pilocytic Astrocytoma
Schwannomas, Dermoid
Epidermoid Tumors

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

84. 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

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