JICNAR○| Journal of the International
Child Neurology Association
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A rare case of hemorrhagic mineralising angiopathy after trivial
head trauma
Yareeda Sireesha
1, Niloufer Ali2, Mathukumalli Lakshmi Neeharika
2, Meena Angamattu
Kanikannan3
1Department of Neurology, Nizam’s Institute of Medical Sciences, Hyderabad, Telangana, India,
2Nizam’s Institute of Medical Sciences, Hyderabad, India, Department of Pathology, Nizam’s Institute
of Medical Sciences, Hyderabad, India
Corresponding author: Meena Angamattu Kanikannan; Email: mailforsiree@gmail.com
Received: 31 Mar 2018
Accepted: 29 Dec 2019
Abstract
Infarction of the basal ganglia after minor head injury is a well described entity .’Mineralising angiopathy’ is a term to
describe mineralisation along the lenticulostriate vessels that predisposes infants to stroke,even after trivial head injury.
The prognosis in these children is excellent.The supratentorial compartment is relatively mobile in comparision to the fixed
infratentorial compartment offering greater shearing forces between the perforating vessels and the brain parenchyma
following an acute trauma. The acute angulation of the lenticulostriate perforators is further responsible for its propensity
of the basal ganglia for the insult. The current report is unique as it presents a young boy with hemorrhagic stroke in the
basal ganglia after a trivial trauma and imaging findings suggestive of mineralising angiopathy.
Kewords: mineralising angiopathy, basal ganglia infarct, lenticulostriate vessels.
© Sireesha Y; licensee JICNA
Introduction
from nose, mouth or ear. He did not sustain any external in-
juries. An hour later, he noticed sudden onset weakness of
Infarction of the basal ganglia after minor head injury is
right upper and lower limb and deviation of angle of mouth
a well-described entity. ‘Mineralising angiopathy’ is a term
to the left. His blood pressure when he was brought to
to describe mineralisation along the lenticulostriate vessels
the hospital was 110/70 mmHg. All his peripheral pulses
(LSV) and is usually seen after a trivial head injury with
were regular in volume and character and normal in rate
a presentation as acute stroke [1].The prognosis in these
and rhythm. Cardiac examination was normal. He had an
children is excellent. The supratentorial compartment is
upper motor neuron palsy of the right seventh nerve. The
relatively mobile in comparision to the fixed infratentorial
power was 0/5 in the right upper and lower limb according
compartment, offering greater shearing forces between the
to MRC (medical research council) grading, with extensor
perforating vessels and the brain parenchyma following an
plantar reflex and brisk deep tendon reflexes on the right.
acute trauma [2]. The acute angulation of the lenticulostri-
The rest of the neurological examination was normal.
ate perforators is another postulate, suggesting the propen-
Investigations showed hemoglobin of 12.5g/dL, a nor-
sity of the basal ganglia for the insult [3]. In this case re-
mal differential white blood cell count and platelets, and
port, we present a young boy with hemorrhagic stroke in
no evidence of coagulopathy. His vasculitic profile in-
the basal ganglia after a trivial trauma and with imaging
cluded the presence of titres in the serum antinuclear an-
findings suggestive of mineralising angiopathy.
tibodies (ANAs), antibodies to extractable nuclear antigens
(ENAs), anti-native DNA antibodies (anti-DNA), topoiso-
merase I antibodies (Scl-70), antibodies to cyclic citrulli-
Case description
nated peptides (anti-CCP), rheumatoid factor (RA factor),
A nine-year-old boy presented with a history of trivial head
C-ANCA (myeloperoxidase) and p-ANCA (proteinase 3) lev-
injury over the left parietal area after a trivial fall while play-
els, which were normal. Serological markers, including
ing cricket. He had no loss of consciousness, nor bleeding
both IgG and IgM antibodies against cytomegalovirus, toxo-
1
plasma, rubella and herpes, were negative. He was negative
for HIV (human immunodeficiency virus) and the Hepatitis
B surface antigen test. An electrocardiogram (ECG) and a
two-dimensional echocardiography (2D Echo) were normal.
A metabolic work-up test, including serum calcium, phos-
phorus, magnesium, thyroid, parathormone and vitamin D
levels, was normal. A sickling test was negative.
A computerised tomogram (CT) of the brain revealed hy-
perdensity in the left basal ganglia and a small speck of
hyperdensity on the right (Figure 1). MRI (magnetic res-
onance imaging) confirmed the bleed in the left basal gan-
glia and showed no other parenchymal changes while the
MRA (magnetic resonance angiogram) was normal. Pos-
Figure 2 A CT brain plain axial section at the level of the midbrain,
sibilities considered were mineralising angiopathy with a
showing the tiny speck of calcification in the left basal ganglia.
hemorrhage in the left basal ganglia after a trivial trauma
and an arteriovenous malformation. The patient was ad-
with a greater risk of basal ganglia strokes [7].
How does such a trivial trauma predispose to strokes?
One postulate is that shearing stresses across the miner-
alised lenticulostriate vessels may lead to a spasm of the
vessel, leading to thrombotic occlusion1. In the literature
so far, the reason for the predisposition of stroke in the in-
fantile age group [8] and the follow-up evidence for per-
sistently mineralised vessels as they grow up is not clearly
defined.
This report is unique as it highlights the presence of hem-
orrhagic stroke following a trivial trauma, with an excellent
recovery in a young child.
Vascular anomalies such as arterio-venous malformations
Figure 1 A CT brain plain showing a comma-shaped hyperdensity
are a differential, but was thoroughly ruled out by the dig-
in the left lentiform nucleus, suggestive of hemorrhage. A single
ital subtraction angiographic study. Moreover,the follow-up
dot of hyperdensity in the right basal ganglia is suggestive of a
images showed mineralisation along the lenticulostriate ves-
mineralised vessel.
sels. The presence of a single mineralised vessel, even in
the opposite basal ganglia, further confirmed the diagnosis
vised physical therapy and was followed up. Over the next
of mineralising angiopathy.
three months, his strength improved significantly. He was
Around
20
children between seven months and
17
walking with a mild drag of the left foot that was barely
months with mineralising angiopathy were described re-
noticeable and had a subtle weakness of hand grip. A CT
cently [9]. In contrast, this study is a description of a hem-
scan of the brain was repeated that showed resolution of
orrhage in a young boy. A possible hypothesis could be that
the bleed (Figure 2). A DSA (digital subtraction angiogram)
the cumulative dynamics of the ongoing mineralisation at
showed as normal three months after the stroke and so ex-
a later age probably protect vessels from spasm and throm-
cluded a vascular malformation. Thus, a final diagnosis of
bus, preventing the shear stress and rupture of an ineffi-
a hemorrhagic stroke caused by underlying mineralising an-
ciently mineralised vessel after a trivial trauma. Traumatic
giopathy could be made.
dissection of the lenticulostriate vessels leading to hemor-
rhage could be another possibility [5].
Discussion
Conclusion
Lenticulostriate vasculopathy (LSV) is a well-known entity
[4]. It descibes the hyperechoic vessels seen in the region
Mineralising arteriopathy is a common etiology for ischemic
of the basal ganglia or the thalamus. Such an entity is seen
strokes in children. This study highlights that it could even
in less than two percent of all childhood strokes, particu-
lead to haemorrhage. The patient described in the report
larly after minor trauma [1], [5]. The etiology of these
was older and might offer a reason for the etiological sub-
LSVs is not clear. Cytomegaloviral infections can present
type of this stroke in terms of pathogenesis and the vessel
as periventricular calcifications [6] and is suspected in pa-
wall dynamics, which is different to the infarcts described so
tients with LSV of a higher grade (multiple branches and
far. There is a need to further follow-up patients with inci-
higher echogenicity) on a neurosonogram and is associated
dental mineralising angiopathy beyond infancy, to establish
2
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Competing interests
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The authors have declared that they have no competing in-
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All the authors contributed to and also critically reviewed
[8]
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This is an Open Access article distributed under the
[9]
Goraya JS, Berry S, Saggar K, Ahluwalia A. Stroke After
terms of the Creative Commons Attribution License
Minor Head Trauma in Infants and Young Children With
Basal Ganglia Calcification: A Lenticulostriate Vascu-
mits unrestricted use, distribution, and reproduction in any
lopathy? Journal of child neurology. 2018;33(2):146-
medium, provided the original work is properly credited.
152.
The Creative Commons Public Domain Dedication waiver
applies to the data made available in this article, unless
otherwise stated.
Cite this article as:
Sireesha Y, Ali N, Neeharika M, Kanikan-
nan MA. A rare case of hemorrhagic mineralis-
ing angiopathy after trivial head trauma.
JICNA
[Internet].
2019Dec.19;1(1).
Available from:
2019-141
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