Periventricular Calcification
Susan I. Blaser, MD, FRCPC
DIFFERENTIAL DIAGNOSIS
Common
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TORCH, General
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Congenital CMV
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Congenital Toxoplasmosis
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Congenital Herpes Encephalitis
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Congenital HIV
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Congenital Rubella
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Tuberous Sclerosis Complex
Less Common
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Neurocysticercosis
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Tuberculosis
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Ventriculitis (Chronic)
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Germinal Matrix Hemorrhage
Rare but Important
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Radiation and Chemotherapy
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Pseudo-TORCH
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Aicardi-Goutières Syndrome
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Coats-Plus Syndrome
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ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
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Look for associations
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Brain destruction
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Malformations
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Other loci of calcification
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History
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Helpful Clues for Common Diagnoses
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TORCH, General
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Classic acronym for congenital infections
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Caused by transplacental transmission of pathogens
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Toxoplasmosis
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Rubella
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Cytomegalovirus
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Herpes
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All cause parenchymal calcifications
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Most can cause lenticulostriate mineralization, vasculopathy
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Some (CMV) cause migrational defects
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Some (syphilis, herpes) cause meningitis, meningoencephalitis
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Some (e.g., CMV) cause germinolytic cysts
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Others (e.g., rubella, HSV) cause striking lobar destruction/encephalomalacia
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Congenital HIV, syphilis also considered part of TORCH
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Consider congenital HIV
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If bilateral symmetric basal ganglia calcifications identified in child > 2 months old
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If congenital infection is diagnostic consideration, obtain NECT to detect calcifications
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Congenital CMV
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Most common cause of intrauterine infection in USA
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Timing of infection predicts pattern of damage
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Hypomyelination
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Cortical gyral anomalies
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Microcephaly
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Symmetric periventricular calcifications in 30-70%
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Congenital Toxoplasmosis
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Periventricular and scattered calcifications
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Hydrocephalus (colpocephaly-like)
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Congenital Herpes Encephalitis
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Calcification pattern varies in HSV2
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Asymmetric periventricular
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Scattered periventricular and deep gray
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Subcortical white matter and cortex
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Calcification pronounced in foci of hemorrhagic ischemia
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Like rubella, rare cause of “stone brain”
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Brain atrophy or cystic encephalomalacia
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Focal or diffuse
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Congenital HIV
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Vertical HIV infection
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Basal ganglia calcifications
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Atrophy
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Consider congenital HIV
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If bilateral symmetric basal ganglia calcifications present and child is > 2 months old
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Congenital Rubella
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Periventricular and scattered calcifications
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Scattered or hazy basal ganglia calcifications
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Rarely “stone brain”
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Extensive gyral calcification
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Gliosis
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Micro-infarcts
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Tuberous Sclerosis Complex
Helpful Clues for Less Common Diagnoses
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Neurocysticercosis
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Best clue: Dot inside cyst
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Usually convexity subarachnoid space
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Also gray-white junction, intraventricular
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Nodular calcified (healed) stage
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Shrunken calcified nodule
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Tuberculosis
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Best diagnostic clue
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Basal meningitis
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Pulmonary tuberculosis
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Acute
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Typically basal meningitis
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± localized CNS tuberculoma
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Chronic
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Residual pachymeningeal
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± localized calcifications
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“Target” sign
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Calcification surrounded by enhancing rim (not specific)
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Ventriculitis (Chronic)
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Areas of prior hemorrhagic infarction prone to dystrophic calcification
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Germinal Matrix Hemorrhage
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Occasional ependymal, germinal matrix calcific foci
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Helpful Clues for Rare Diagnoses
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Radiation and Chemotherapy
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History
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Mineralizing microangiopathy
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Pseudo-TORCH
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Aicardi-Goutières Syndrome
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“Mendelian mimic of congenital infection”
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Multifocal punctate calcifications
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Variable locations including periventricular white matter, basal ganglia, dentate nuclei
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Elevated CSF interferon (IFN-α)
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TREX1 mutations in some
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Coats-Plus Syndrome
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a.k.a. cerebroretinal microangiopathy with calcifications and cysts
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Ocular coats: Retinal telangiectasia and exudate
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CNS small blood vessel calcification
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Extensive thalamic and gyral calcification
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Defects of bone marrow and integument
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Growth failure
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Image Gallery
![]() Sagittal T2WI MR shows a thick cortex with small gyri, hyperintense white matter
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