Left thalamic hemorrhage. Also, history of fall with neck injury. BRAIN MRI:The left thalamic hematoma has not changed since the CT scan from yesterday, measures in the axial plane 2.1 cm x 1.3 cm. It shows signal characteristics that are compatible with its early subacute nature (peripherally T1-hyperintense and T2-hypointense). It is surrounded by moderate degree of vasogenic edema resulting in mass-effect on the third ventricle and the posterior limb of the left internal capsule as well as lentiform nucleus, which is not significantly changed also compared to the previous scan. Susceptibility weighted imaging shows multiple other scattered foci of hemosiderin staining in the cerebrum indicative of previous hemorrhages. Many of these are in periventricular and central in distribution.There is multifocal diffusion restriction involving the left external capsule, the parafalcine posterior frontal lobes (left more than right) as well as the right inferior frontal gyrus. In addition, there is diffusion restriction just deep to the posterior aspect of the right cingulate sulcus. There are foci of diffusion restriction in the left cerebellar hemisphere. A tiny focus of diffusion restriction is present in the left hemipons as well. There is diffusion restriction in the inferior fibers of the splenium of the corpus callosum, which likely reflects acute Wallerian generation. In addition, there is symmetric bright T2 and diffusion signal within the middle cerebellar peduncles which shows relatively isointense ADC signal. This may reflect metabolic injury or drug toxicity.Confluent cerebral white-matter T2/FLAIR hyperintense signal without diffusion restriction is compatible with chronic microvascular ischemia. Similar changes are present in the midbrain and pons. The right occipital chronic infarct and the associated leukomalacia as well as cortical laminar necrosis remain unchanged. Multiple scattered chronic lacunar infarcts involving the thalami, basal ganglia, and cerebellum are also not significantly changed. Accounting for mass effect caused by the left thalamic hematoma, the remainder of the ventricular system is mildly dilated reflective of diffuse brain volume loss. There is no brain herniation.There is mild mucosal thickening in the mastoid air cells and paranasal sinuses. There are secretions in the posterior nasopharynx. An esophagogastric tube traverses the right nasal cavity. There is an endotracheal tube through the oral cavity. There is bilateral proptosis without significant orbital abnormality otherwise.CRANIAL MRA:The intracranial internal carotid arteries become irregular in caliber and attenuated in their cavernous segments which probably reflects atherosclerotic involvement. This is more pronounced at the anterior genu of the cavernous segment of the right internal carotid artery which is significantly attenuated. Similar irregularity is present throughout the anterior and middle cerebral arteries and the major branches. This is most pronounced at the proximal A2 segment. A small anterior communicating artery is probably present.The left intradural vertebral artery is very attenuated with segmental complete loss of flow-related signal. The basilar artery and the right vertebral artery show irregularly narrowed caliber but no not flow limiting stenoses, reflective of atherosclerotic involvement. Both posterior-inferior cerebellar arteries are not definitively visualized. The anterior inferior and the superior cerebellar arteries are patent although atherosclerotically narrowed, especially the origin of the right anterior-inferior cerebellar artery. The posterior cerebral arteries are very small, more on the right. The left posterior communicating artery is larger than the associated P1 segment, with a fetal-type PCA. The right posterior communicating artery is not well visualized.Overall appearance has not significant change compared to the previous MRA.CERVICAL SPINE MRI:Alignment is notable for 2 mm of posterior subluxation of C5 relative to C6. The vertebral bodies are preserved in height. Anterior osteophytes are most pronounced at C5-C6 and C6-C7 levels. The intervertebral discs are unremarkable for mild height loss at C5-C6 and relative preservation of the other levels. The spinal canal is moderately to markedly narrowed at C4-C5 and C5-C6 levels. The spinal cord shows no abnormal signal although it is indented by the C5-C6 degenerative disc-osteophyte complex. There is increased T2 signal within and in between the paraspinal muscles along the cervical spines, which is more pronounced on the left, and may represent muscle sprain.C2-C3 and C3-C4: There is shallow anterior indentation of the thecal sac by degenerative disc-osteophyte complex but no significant spinal canal or foraminal stenosis.C4-C5: The disc-osteophyte complex partially effaces the CSF around the spinal cord resulting in mild spinal canal stenosis. There is no significant foraminal stenosis.C5-C6: Disc-osteophyte complex mildly deforms the spinal cord at this level causing moderate spinal canal stenosis. There is mild-to-moderate right and minimal left neuroforaminal stenoses by uncovertebral and to a lesser extent facet arthropathy. C6-C7 and C7-T1: There is no significant spinal canal or foraminal stenosis.There is an incidental finding of a 2.4 cm right thyroid lobe nodule which is heterogeneously T2-hyperintense. The endotracheal tube and esophagogastric catheter are included.
1.Stable appearance of evolving subacute left thalamic hematoma with surrounding vasogenic edema and localized mass-effect. Multiple other foci of hemosiderin staining are present centrally in the brain reflective of previous hemorrhage as, probably hypertensive in nature.2.Multiple scattered cerebral, left pontine and cerebellar recent infarcts, probably embolic given the multifactorial distribution. Diffusion restriction in the splenium of the corpus callosum is probably acute neuronal degeneration. 3.Symmetric T2 signal in the middle cerebellar peduncles is nonspecific and may reflect metabolic injury or drug toxicity. Alternatively, it may relate to chronic small vessel ischemia.4.Changes of chronic microvascular ischemia, chronic infarcts and global brain volume loss are unchanged.5.Essentially stable MRA head demonstrating multifocal attenuation of the intracranial arteries are reflective of atherosclerotic involvement. The diminutive left vertebral artery might be congenital variation or may reflect severe atherosclerosis.6.Disc-osteophyte complex at C5-C6 mildly deforms the spinal cord but without abnormal signal, reflecting moderate spinal canal stenosis.7.Right thyroid lobe nodule. If further assessment is clinically warranted, thyroid ultrasound is recommended.Dr. Monther Qandeel discussed the above findings with Dr. Tania Rebeiz over the phone on January 3, 2016 at 1505 hours. 