What is the management approach for an adult patient with a 3mm calcification in the anterior falx, with or without neurological symptoms such as seizures, headaches, or cognitive changes?

Management of 3mm Anterior Falx Calcification

A tiny 3mm calcification in the anterior falx is almost certainly a benign, incidental finding that requires no treatment or intervention in an asymptomatic adult patient. 1

Initial Assessment

Determine if the patient has any neurological symptoms:

• Seizures (new-onset or recurrent)
• Headaches (progressive or severe)
• Cognitive changes
• Focal neurological deficits
• Gait disturbances 2

The presence or absence of symptoms fundamentally determines the management pathway.

Asymptomatic Patients (Most Common Scenario)

No intervention is required for asymptomatic patients with small falx calcifications. 1

• Small calcifications in the falx cerebri are common incidental findings on neuroimaging and typically represent benign age-related changes or remote granulomatous disease 1
• A 3mm calcification is too small to cause mass effect or neurological dysfunction 2
• No follow-up imaging is necessary unless new symptoms develop 1
• No antiepileptic drugs are indicated in the absence of seizures 1
• No antiparasitic treatment is needed even if the calcification represents a calcified granuloma, as these represent dead parasites 1

Important Caveat for Young Patients

If the patient is under 20 years old with falx calcification, consider screening for Gorlin-Goltz syndrome (nevoid basal cell carcinoma syndrome), as lamellar falx calcification is pathognomonic for this condition 3, 4. Look for:

• Multiple basal cell carcinomas
• Jaw cysts (odontogenic keratocysts)
• Palmar/plantar pits
• Family history of the syndrome 3, 4

Symptomatic Patients with Seizures

If seizures are present, treat the seizures with antiepileptic drugs, not the calcification itself. 1

First-Line Antiepileptic Drug Selection

Levetiracetam or lamotrigine are the preferred agents due to superior tolerability and lack of drug interactions 1

• Start levetiracetam 500mg twice daily, titrate as needed
• If psychiatric side effects occur with levetiracetam (irritability, mood changes), switch to lamotrigine or valproate 1
• Avoid phenytoin, phenobarbital, and carbamazepine due to problematic side effects and drug interactions 1
• Never use phenytoin in patients with any intracranial pathology due to associated excess morbidity and mortality 1

Diagnostic Workup for Seizure Patients

Obtain brain MRI with and without contrast to evaluate for perilesional edema or other associated findings 1

• MRI is superior to CT for detecting inflammation around calcifications 1, 5
• Look for blood-brain barrier dysfunction (enhancement) suggesting active inflammation 5
• Check for additional lesions not visible on CT 1

Check serum electrolytes, particularly potassium and calcium levels 6

• Hypokalemia below 3.0 mmol/L can cause seizures in elderly patients 6
• Hypocalcemia can trigger seizures at any age 7

Duration of Antiepileptic Therapy

Consider tapering antiepileptic drugs after 6 months of seizure freedom, but only if no risk factors for recurrent seizures are present 1

What NOT to Do

Critical pitfalls to avoid:

• Do not prescribe antiparasitic drugs (albendazole or praziquantel) for calcified lesions—they provide no benefit as the parasites are already dead 1
• Do not routinely prescribe corticosteroids for isolated calcified lesions without perilesional edema 1
• Do not use phenytoin in patients with intracranial calcifications 1
• Do not order follow-up imaging in asymptomatic patients with stable, small calcifications 1

Special Consideration: Perilesional Edema

If MRI shows perilesional edema around the calcification in a patient with recent seizures 5:

• This represents inflammatory reactivation around the calcified focus 5
• Episodes typically resolve spontaneously within 4-6 weeks 5
• Treatment remains supportive with antiepileptic drugs 1, 5
• Corticosteroids may be considered for severe, symptomatic edema, but are not routinely recommended 1
• Repeat MRI in 6 months to document resolution 1

Refractory Cases

For patients with medically refractory epilepsy despite optimal antiepileptic therapy, consider evaluation for surgical removal of the seizure focus with preoperative seizure mapping 1