Caseous calcification of the mitral annulus as a rare cause of embolic stroke in a young patient with end-stage renal disease: a case report.

Background: Caseous calcification of the mitral annulus (CCMA) is a rare form of mitral annular calcification and may be an embolic source, particularly in end-stage renal disease (ESRD). Case summary: A 33-year-old man with ESRD on haemodialysis presented with acute left middle cerebral artery stroke (NIHSS 21). Brain CT angiography showed a dense calcified embolus occluding the proximal M1 segment. Echocardiography and ECG-gated non-contrast cardiac CT identified two posterior annular lesions with a calcified rim and central low-attenuation, consistent with CCMA. The close radiological match between the intracranial calcified embolus and the annular lesions suggested CCMA as the most plausible source. Surgical excision was deferred after multidisciplinary discussion because of the high haemorrhagic risk related to the large recent infarction. The patient was managed conservatively with oral anticoagulation and strict blood pressure control. Discussion: This case illustrates that CCMA may be a possible embolic source even in young dialysis patients. It underscores the diagnostic value of multimodality imaging and the importance of individualized multidisciplinary decision-making when weighing embolic and haemorrhagic risks.