Reason: altered mental status, evaluate for CVA or other lesions History: as above MRI BRAIN: There is an area of restricted diffusion in the left frontal lobe involving the middle and inferior frontal gyri. Additional, smaller areas of restricted diffusion are noted along the right insula and external capsule as well as the left periventricular white matter of the occipital horn. Microhemorrhages in both thalami appear increased from the prior exam. Periventricular FLAIR signal abnormality is consistent with small vessel ischemic disease. There are old lacunar infarcts in both thalami in addition to the left ventral pons. There is no evidence of a mass. Parenchymal volume loss appears to preferentially affect the parietal and temporal lobes. No abnormal extra-axial fluid collection is identified. There is no midline shift or mass effect. The midline structures and craniocervical junction are within normal limits. Normal flow-voids are demonstrated in the major intracranial vascular structures.The paranasal sinuses are clear. The visualized mastoid air cells are clear. The orbits are unremarkable.MRA BRAIN: The exam is significantly limited by patient motion artifact. There is intracranial atherosclerotic disease without evidence of significant major vessel stenosis. The right ICA is larger than the left. There are multiple intracranial aneurysms including a 2.5 mm proximal basilar aneurysm, 3 mm right P-comm aneurysm, 3 mm right sub hypophyseal right ICA aneurysm and 3 mm ACOM aneurysm. There is also a 1 to 2 mm outpouching arising from the left cavernous ICA, which likely represents a small aneurysm verus prominent infundibulum. The right ACA is dominant. The middle cerebral arteries appear normal. There is a fetal origin of the right PCA. The left vertebral artery is dominant. The right vertebral artery primarily supplies the PICA. The basilar artery appears normal. There is no evidence of flow-limiting stenosis.MRA NECK: There is a separate origin of the innominate, left common carotid and left subclavian arteries from the aortic arch. The origin of the left vertebral artery is not well-seen but the remainder of the vessel is well opacified. The origin of the right vertebral artery is widely patent. The distal right vertebral artery is attenuated but remains opacified. The common and cervical internal carotid arteries are normal in course. There is mild narrowing of the proximal left ICA without evidence of significant stenosis by the NASCET criteria.
1.Areas of restricted diffusion in the middle and inferior left frontal gyri and additional, smaller areas of restricted diffusion in the right insula and external capsule as well as the left periventricular white matter of the occipital horn are consistent with acute cerebral infarcts in multiple territories. 2.Multiple intracranial aneurysms including a 2.5 mm proximal basilar aneurysm, 3 mm right P-comm aneurysm, 3 mm right sub hypophyseal right ICA aneurysm and 3 mm ACOM aneurysm. There is also a 1 to 2 mm outpouching arising from the left cavernous ICA, which likely represents a small aneurysm verus prominent infundibulum.3.No evidence of flow-limiting stenosis in the head or neck. There are intracranial atherosclerotic changes present.4.There are microhemorrhages present in the thalami which have accumulated further since the previous exam from 20115.Old lacunar infarcts in the brainstem and basal ganglia.6.Periventricular and subcortical white matter lesions of a moderate degree are nonspecific. At this age they are most likely vascular related. 7.The left vertebral artery is not readily identified. It's possible this is artifactual appearance though the possibility of a left vertebral artery stenosis cannot be excluded.