# 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

## TL;DR

A young dialysis patient had a stroke caused by caseous calcification of the mitral annulus, highlighting its rare embolic potential and the need for careful diagnosis and treatment.

## Contribution

This case report highlights CCMA as a rare embolic source in young ESRD patients and emphasizes the role of multimodal imaging in diagnosis.

## Key findings

- CCMA was identified as the likely source of embolic stroke in a 33-year-old ESRD patient.
- Multimodal imaging confirmed calcified lesions matching the intracranial embolus.
- Conservative management was chosen over surgery due to high hemorrhagic risk.

## Abstract

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).

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.

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.