Clinical question: possible stroke. Signs and Symptoms: as above. Nonenhanced brain MRI:There is no evidence of an acute ischemic stroke.Examination demonstrate diffuse left hemispheric periventricular and subcortical FLAIR hyperintensity of brain parenchyma and to a lesser degree of the left basal ganglia associated with mild ex vacuo dilatation of left lateral ventricle suggesting chronic ischemic changes in the microvascular distribution. Compared to prior exam there is significant interval progression of finding in the left hemisphere.Very minimal similar finding on the right side is also noted. Significant discrepancy of the findings on the left suggest possibility of proximal large vessel vascular stenosis. There is mild left-sided medullary and degeneration.Cortical sulci are prominent for patient's stated age however without detectable signal abnormality.Images through posterior fossa demonstrate focus of encephalomalacia in the right middle cerebellar peduncle without significant change since prior exam. Also similar to prior exam there is prominence of cerebellar and vermian folia for patient's stated age of 49.The signal void of major intracranial arterial branches are identified. There is persistent low signal changes in the left vertebral and basilar artery with decreased caliber as was noted on prior MRI and CTA examinations.
1.No acute intracranial process and negative diffusion weighted series.2.Extensive left hemispheric periventricular / subcortical and to a lesser degree left basal ganglia FLAIR hyperintensity with volume loss suggesting progression of small vessel distribution ischemic strokes since prior MRI exam. Minimal similar changes in the right hemisphere is also noted. Stable focus of encephalomalacia/chronic stroke in the right middle cerebellar peduncle.3.Asymmetrical (L>R) extent of left hemispheric findings is suggestive of a larger proximal vessel stenosis or occlusion.4.Prominence of cortical sulci and cerebellar-vermian folia for patient of stated age and consistent with underlying parenchymal volume loss.5.Redemonstration of signal changes in the left vertebral artery and proximal basilar with decreased caliber consistent with findings on prior CTA examination.