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Although bilateral basal ganglia lesions are common in hypoxic encephalopathy and methanol intoxication, they are a rare finding in end-stage chronic renal failure. The pathophysiology of both bilateral and selective involvement of the basal ganglia is unclear, but severe metabolic acidosis is one of the affected processes. In this report bilateral basal ganglia lesions and accompanying signs, which ensued after the use of metformin in a patient with chronic renal failure, are discussed