Diagnosis: Headache Cerebral aneurysm, nonrupturedClinical question: assess for thrombus developmentSigns and Symptoms: acute onset left hemiparesis MRI of the brainThere are multiple foci of subcentimeter sized diffusion restriction within the distal right MCA territory along the watershed zone adjacent ot the right superior frontal sulcus and in the right inferior parietal lobule as well as in the right with several mor scattered in the right frontal and parietal lobes. In addition, there are Periventricular and and subcortical white matter signal hyperintensities identified on FLAIR MRI without diffusion restriction some of which were not present on the 10/19/15 exam. The CSF spaces are appropriate for the patient's stated age with no midline shift. Normal vascular flow voids are present in the distal carotid and vertebral arteries, the basilar artery and the proximal anterior, middle and posterior cerebral arteries as well as the internal cerebral veins and superior sagittal sinus.The visualized portions of the paranasal sinuses demonstrate small air-fluid levels in the maxillary sinuses and left sphenoid sinus and scattered opacities in the ethmoid air cells. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact.MRA brain:Embolic occlusion coils are present at the patient's right anterior choroidal bilobed aneurysm (which is embedded into the medial aspect of the right temporal lobe) and the patient's basilar aneurysm. The anterior choroidal artery remains patent. There is no evidence for recanalization of either aneurysm at this time.There is redemonstration of a 2mm right ophthalmic artery aneurysm at the origin of the right ophthalmic artery. There is redemonstration of a left superior cerebellar origin 1 mm aneurysm. There is redemonstration of a 1 mm left PCOMA aneurysm.Antegrade flow is present in the distal internal carotid arteries, the distal vertebral arteries, the basilar artery and the proximal anterior, middle and posterior cerebral arteries.The anterior communicating artery is identified. The posterior communicating arteries are small. The left vertebral artery is slightly smaller than the right vertebral artery.
1.Multiple subcentimeter foci of infarction predominantly located along the right hemispheric watershed zone. These could be related to distal emboli.2.No evidence for cerebrovascular occlusion.3.Status post embolic coil occlusion of a right anterior choroidal artery aneurysm without evidence for recanalization at this time and no change since the MRA earlier in the day. This aneurysm is embedded in the right temporal lobe.4.Status post embolization of a basilar/left AICA origin aneurysm without evidence for recurrence.5.Findings were discussed with Dr Kramer at the time of the exam.6.There is redemonstration of a 2mm right ophthalmic artery aneurysm at the origin of the right ophthalmic artery. 7.There is redemonstration of a left superior cerebellar origin 1 mm aneurysm.8.There is redemonstration of a 1 mm left PCOMA aneurysm.