Stroke After Minor Head Trauma in Infants and Young Children With Basal Ganglia Calcification: A Lenticulostriate Vasculopathy?

Abstract

The authors retrospectively reviewed charts of the children with basal ganglia stroke who either had preceding minor head injury or showed basal ganglia calcification on computed tomography (CT) scan. Twenty children, 14 boys and 6 girls were identified. Eighteen were aged between 7 months to 17 months. Presentation was with hemiparesis in 17 and seizures in 3. Preceding minor head trauma was noted in 18. Family history was positive in 1 case. Bilateral basal ganglia calcification on CT scan was noted in 18. Brain magnetic resonance imaging done in 18 infants showed acute or chronic infarcts in basal ganglia. Results of other laboratory and radiological investigations were normal. Four infants were lost to follow-up, 9 achieved complete or nearly completely recovery, and 7 had persistent neurological deficits. Basal ganglia calcification likely represents mineralized lenticulostriate arteries, a marker of lenticulostriate vasculopathy. Abnormal lenticulostriate vessels are vulnerable to injury and thrombosis after minor head trauma resulting in stroke.

Infantile Basal Ganglia Stroke after Mild Head Trauma Associated with Mineralizing Angiopathy of Lenticulostriate Arteries: An Under Recognized Entity

“…Remarkably, nine of them were found to have anemia (hemoglobin < 11 g/dL), with microcytosis in six and low serum iron or low ferritin in 11 individuals. On the other hand, IDA was not mentioned as a risk factor or finding in all remaining published cases of mineralizing angiopathy 1,5,[8][9][10][11][12][13][14][15]20 despite the high prevalence of IDA in exactly this age group.…”

“…Basal ganglia calcification was identified in 44.8% of individuals with mild head trauma, though in none of the controls. Goraya et al 15 reported recently on a retrospective study of 20 children with basal ganglia stroke who either had a preceding minor head injury or showed basal ganglia calcification on CT. Eighteen were aged between 7 months and 17 months. Bilateral basal ganglia calcification was noted in 18/20 children.…”

“…Overall, the finding of acute cerebral infarction in children with associated calcification in the basal ganglia was only reported in a few single case reports [8][9][10][11][12][13][14]18 and three retrospective studies. 1,5,15 Remarkably, this entity is not mentioned as a risk factor in follow-up reports about large pediatric stroke cohorts. 16,17 MRI is the preferred imaging modality in stroke patients, but it does not detect mineralization of the lenticulostriate arteries.…”

“…This high recurrence rate was only realized because of the repeated imaging, and the question is whether a longer follow-up and repeated imaging studies would have shown higher recurrence rates also in the larger published studies. 1,5,15 Our five patients are all males and it is evident that in the published cases of basal ganglia infarction after head trauma and mineralizing angiopathy including our individuals the males outnumber the females by 52 males (73%) in contrast to 19 females (27%) (Lingappa et al 1 16 males /22, Yang et al 5 11 males /16, Goraya et al 15 14 males/20, Kamate et al 10 2 males /2, Jain et al 8 1 male /1, Yang et al 9 1 male /1, Ivanov et al 13 1 male/1, Sonam et al 14 1 male/1, Fidan et al 11 1 female /1, Arora et al 12 1 female /1). This male preponderance was not discussed in the earlier reports.…”

“…One of our patients had IDA. From the Indian cohort of patients with basal ganglia stroke and calcification, 15 complete blood counts were available in only 13 of 20 enrolled children. Remarkably, nine of them were found to have anemia (hemoglobin < 11 g/dL), with microcytosis in six and low serum iron or low ferritin in 11 individuals.…”