A 63-year-old woman with advanced chronic kidney disease, diabetes mellitus, hypertension and peripheral vascular disease presented with three successive tonic–clonic seizures. She was obtunded, with a Glasgow coma scale score of 4/15 but with no lateralising neurological signs. She had marked renal impairment (serum creatinine 606 mmol/L (49–90) and estimated glomerular filtration rate of 6 mL/min/1.73 m 2 (>60)). There was severe hyperparathyroidism (parathyroid hormone 48.8 pmol/L (1.7–7.6)). CT scan of the head found widespread infratentorial and supratentorial calcifica-tions, unchanged from a CT scan 2 years before, and subtle acute subdural and subarachnoid haemorrhages (figure 1). She remained comatose and died 14 days later. It was not clear whether the intracra-nial haemorrhages were the consequence of convulsion-related trauma or whether the haemorrhage caused the seizures. Intracerebral calcification has a range of causes and the anatomical distribu-tion provides clues to these (box 1). Causes include advanced chronic kidney disease 1 where the main drivers of calcification are phosphate retention and secondary hyperparathyroidism. 2 Intracerebral haemorrhage is more common in patients with chronic kidney disease 3 reflecting the associated co-occurrence of diabetes and hyperten-sion and the bleeding diathesis asso-ciated with uraemia. 4 In this patient, the dramatic and widespread, though clinically innocuous cerebral calcifications could distract the observer from more subtle, yet clinic-ally more important intracranial haemorrhage. Figure 1 Plain axial CT scan of brain showing symmetrical calcification of the centrum semiovale (A–C), basal ganglia (D and E) and cerebellum (F). The thin white arrows show hyperdense right posterior parafalcine (A and B) and minor left frontoparietal subdural haematoma (A–C) with adjacent sulcal effacement. Thick white arrow indicates cortical SAH (C). White arrows demonstrate asymmetrical subcortical (D) and cortical occipital lobes calcification (E).
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