Calvarial thickening and cerebellar atrophy due to chronic phenytoin use
Dementia screen. Past history of cranial surgery causing seizures. Many years of phenytoin use.
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Signs of previous skull vault surgery (craniotomy and burr holes) with gross generalised thickening of the skull vault. Left cerebral hemispheric atrophy (cause uncertain but responsible for chronic seizures). Note gross generalised cerebellar atrophy also due to phenytoin use.