CASE 17897 Published on 14.10.2022

Mineralizing microangiopathy as a long term complication of radiotherapy

Section

Neuroradiology

Case Type

Clinical Cases

Authors

Natanael Vázquez, Ricardo Triana

Silao General Hospital, Radiology Department, Silao, Guanajuato, Mexico

Patient

14 years, male

Categories

Area of Interest Neuroradiology brain ; Imaging Technique CT

No Procedure ; No Special Focus ;

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Clinical History

A 14-year-old male patient with history of supratentorial ependymoma that was excised and received chemotherapy and radiotherapy 4 years prior was brought for evaluation due to persistent headache.

Imaging Findings

A contrast enhanced CT scan was obtained showing surgical changes associated with tumoral excision, bilateral subdural hygroma, a left ventricular shunt, and multiple calcified gyriform subcortical areas in both frontal and temporal lobes; there were also calcifications located at the basal ganglia bilaterally.

Discussion

Chemotherapy and radiotherapy for the management of CNS neoplasms have a toxic effect on brain tissue, being brain tissue volume loss the most common long-term complication [1]

Mineralizing microangiopathy is an rare long-term complication of these therapies in children, being present in 28% of survivors, and it´s more frequent when the therapies are combined [2]. It represents the deposition of calcium in small vessels secondary to fibrinoid necrosis [3]. Therapy for meduloblastoma is recognized as the main cause in some series, while treatment for leukaemia and craneopharyngiomas represent a common cause as well. The most prevalent symptoms are headache, convulsions and slurred speech, although some patients are asymptomatic [4]

On imaging, it presents a dystrophic calcification located at the basal ganglia, cortico-subcortical junction and cerebellum [5]. When located at the basal ganglia, it may increase the risk of stroke after minor trauma due to affection of lenticulostriate arteries [6].

No firm recommendations are available at the moment regarding the management of these patients [7]; however, preventive care is recommended to minimize reversible stroke risk factors [8].

Conclusion

Mineralizing microangiopathy is an uncommon complication of CNS neoplasms management. As survival rates increase among these patients, it will become more prevalent in the future. Since it increases the risk of basal ganglia stroke, it is very important for radiologists to learn to recognize it so that it’s not mistaken for other entities, and preventive management can be started early.

‘Written informed consent for publication from the patient’s mother has been obtained.’

Differential Diagnosis List

Mineralizing microangiopathy

Leptomeningeal carcinomatosis

Cortical laminar necrosis

Subarachnoid haemorrhage

Fahr's disease

Final Diagnosis

Mineralizing microangiopathy

References

[1] Vázquez, Elida, et al. Side effects of oncologic therapies in the pediatric central nervous system: update on neuroimaging findings. Radiographics 31.4 (2011): 1123-1139.

[2] Srinivasan KG, Ramprabananth S, Ushanandhini KP, Srividya S, Kumar MP. Radiation-Induced Mineralizing Microangiopathy in a Case of Recurrent Craniopharyngioma: A Case Report. The Neuroradiology Journal. 2010;23(4):412-415.

[3] Mamlouk MD, Handwerker J, Ospina J, Hasso AN. Neuroimaging findings of the post-treatment effects of radiation and chemotherapy of malignant primary glial neoplasms. Neuroradiol J. 2013;26(4):396-412.

[4] Youssef, A., Madney, Y., Zaghloul, M. et al. Mineralizing microangiopathy: radiological features of a "not uncommon" complication of chemoradiotherapy in pediatric cancer patients. Egypt J Radiol Nucl Med. 2022;53, 129.

[5] Lewis, E., Lee, YY. Computed tomography fndings of severe mineralizing microangiopathy in the brain. J Comput Tomogr. 1986; 10(4):357–364.

[6] Khalid, M. T., Chan, D. W., Tan, E. E., Seow, W. T., Ng, L. P., Low, D. C., & Low, S. Y. Right middle cerebral artery infarct after minor head trauma in an infant: case report and literature review. International journal of pediatrics and adolescent medicine. 2019; 6(3), 121-124.

[7] Morris, B., Partap, S., Yeom, K., Gibbs, I., Fisher, P., & King, A. Cerebrovascular disease in childhood cancer survivors: A Children’s Oncology Group Report. Neurology. 2009; 73(22), 1906-1913.

[8] Partap, S. Stroke and cerebrovascular complications in childhood cancer survivors. Seminars in pediatric neurology. 2012; 19(1), 18-24.

Case information

URL:	https://www.eurorad.org/case/17897
DOI:	10.35100/eurorad/case.17897
ISSN:	1563-4086

License

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Figure 1

Axial non-enhanced head CT showing gyriform hyperdense (200 Hounsfield units) areas located at gray matter-white matter junction in both frontal lobes and right temporal lobes. Similar areas are found at the basal ganglia bilaterally. There are also bilateral crescent shaped extra-axial areas with fluid density representing subdural hygromas.

A more cephalic slide of the same study shows the same hyperdense areas, subdural hygromas and the tip of the ventricular shunt located in the body of the left lateral ventricle. There is also a left parietal hypodense area representing encephalomalacia as well as an ipsilateral parietal craneotomy associated with tumor excision.

A more cephalic slide of the same study shows more fronto-parietal calcifications; encephalomalacia, craneotomy and subdural hygroma are more evident. The body of the ventricular shunt catheter is seen in the left frontal lobe.

Axial non-enhanced head CT at the site of excision shows no abnormal enhancement. Frontal and basal ganglia calcifications and bilateral subdural hygromas are evident.