69-year-old male with past medical history of COPD, DM, HTN presents to the Emergency Department with left-sided weakness and right eye deviation since 3am today. There is focal diffusion restriction involving the posterior limb of the right internal capsule with superior extension along caudothalamic groove. This is a recent acute/subacute ischemic infarct. In addition, there is extensive confluent periventricular cerebral hemispheric T2/FLAIR hyperintensity without diffusion restriction which represents chronic microvascular ischemia. Patchy similar findings are present the right cerebral peduncle and along the right cortical spinal tract.There is a small focus of susceptibility effect involving the left middle cerebellar peduncle which may represent tiny focus of hemorrhage. Accounting for basal ganglia calcification, there is no supratentorial intraparenchymal hemorrhage.The right eye globe is elongated (versus staphyloma) while the left eye lens is absent.Dynamic contrast imaging was performed. However, the quality of the examination is not optimal, as judged by the arterial input function curve. However, there is no significant asymmetry on the color coded rCBV, rCBF and MTT maps between the 2 cerebral hemispheres.
1.Diffusion restriction in the posterior limb of the right internal capsule is compatible with an acute/subacute infarct in the right anterior choroidal artery territory.2.There is no significant asymmetry between the two cerebral hemispheres on the perfusion maps but the study is technically limited as described above.3.There is no other acute infarct in the brain. Extensive cerebral white changes are most compatible with chronic microvascular ischemia.