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|Year : 2015 | Volume
| Issue : 6 | Page : 979-981
Sturge-Weber syndrome with bilateral cerebral calcifications but without a facial nevus
Surender Kumar1, Sucharita Anand1, Paurush Ambesh2, Vimal Kumar Paliwal1
1 Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
2 Department of Internal Medicine, Moti Lal Nehru Medical College, Allahabad, Uttar Pradesh, India
|Date of Web Publication||20-Nov-2015|
Vimal Kumar Paliwal
Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kumar S, Anand S, Ambesh P, Paliwal VK. Sturge-Weber syndrome with bilateral cerebral calcifications but without a facial nevus. Neurol India 2015;63:979-81
Sturge- Weber syndrome More Details More Details (SWS) is a neurocutaneous syndrome characterized by capillary-venous angiomas involving the face, ipsilateral leptomeninges, and the eye. It is a rare sporadic-congenital syndrome (1/50,000 births) and is generally classified into three types. Type 1 manifests with classical facial nevus, leptomeningeal angioma, and glaucoma; Type 2 SWS presents with facial nevus and glaucoma; whereas, Type 3, the rarest of the three (incidence 5–15%), presents only with isolated leptomeningeal angiomas. Bilateral calcifications can be seen in upto 20% patients with SWS but bilateral affliction without a facial nevus is extremely rare. In the absence of a facial nevus, the disease poses a diagnostic challenge, and therefore, we report this case.
An 8-year-old girl presented with generalized tonic-clonic seizures of 4 year duration associated with behavioral abnormality for 2 years. Her illness started with seizures (frequency 5/year) and soon progressed to poor scholastic performance. Her speech was reduced to single words. She stopped informing about her natural calls. There were no other seizure types, exanthematous illness, head trauma or febrile encephalopathy. She was born full term and had attained her early milestones normally. On examination, she was irritable and hyperkinetic with poor attention span and without any neurocutaneous markers. Her neurological examination was normal including the presence of a normal head size and normal vision/hearing. Her hematological investigations including calcium studies were normal. Cranial computed tomography scan revealed bilateral parieto-occipital atrophy, gliosis, and gyriform calcification. Magnetic resonance imaging of the head revealed leptomeningeal enhancement over the parieto-occipital sulci with underlying periventricular white matter hyperintensities [Figure 1]. Electroencephalography revealed an attenuation of alpha rhythm over the parietooccipital leads [Figure 1].
|Figure 1: (a) Cranial computed tomography scan showing parieto-occipital gyriform calcification; (b) postgadolinium T1-weighted magnetic resonance imaging showing leptomeningeal enhancement (arrows); (c and d) T2 fluid attenuated inversion recovery image showing periventricular and parieto-occipital white matter hyperintensity and cerebral atrophy; (e) electroencephalography, occipital leads (box) showing attenuation of alpha rhythm (12 Hz, frontal/central leads)|
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Differential diagnosis in a child presenting with these manifestations may include inborn errors of metabolism, mitochondrial disorders, childhood epileptic disorders such as Landau-Kleffner syndrome, progressive myoclonic epilepsies, and encephalopathies like subacute sclerosing panencephalitis. However, the radiological assessment of the lesions causing intracranial calcifications in childhood may significantly shorten the list. The causes include congenital TORCH infections, calcified neurocysticercosis, Fahr's disease, tuberous sclerosis, tumors, celiac disease, purulent meningitis, and ossifying meningoencephalitis. TORCH infections, meningitis, and meningoencephalitis produce static encephalopathy. Calcified neurocysticercosis/brain tumors produce nongyriform calcification. Calcifications in Fahr's syndrome involve the globus pallidus, the caudate-putamen complex and the cerebellum (straito-pallidal-dentate region). Our patient lacked subependymal calcifications/tubers of tuberous sclerosis. Celiac disease may cause bilateral occipital calcifications but a preceding history suggestive of malabsorption syndrome was lacking in our patient. Moreover, cognitive dysfunction is uncommon in celiac disease. Additionally, calcification in celiac disease occupies both cortical/subcortical locations and lacks enhancement as well as cortical atrophy/gliosis, quite unlike the findings in our patient.
Electroencephalographic abnormalities in SWS include ipsilateral slowing, attenuation of the background rhythm, and spike-wave discharges. Alpha-rhythm, predominantly seen in occipital leads, was attenuated in our patient possibly due to the abnormal underlying cortex. We conclude that a careful clinico-radiological correlation may be helpful in diagnosing SWS especially when there is lack of a facial nevus.
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