Reason: 3T; chronic right middle cerebral artery occlusion with no evidence of ischemic symptoms, carotid aneurysm, annual surveillance for stability History: near syncope and muscle tightening in past, migraines. Brain MRI:Again noted are minimal and scattered T2/FLAIR hyperintense foci in the left frontal white matter that are nonspecific, unchanged as compared to prior exam. There is no mass effect or midline shift. There is no intracranial hemorrhage. There is no abnormal brain diffusion restriction. The dural venous sinuses are patent. The visualized paranasal sinuses are clear.Cranial MR Angiography:Again noted is fusiform dilatation and tortuosity of the supraclinoid/intradural segment of the right internal carotid artery, with a maximum diameter of 8 mm, extending into and mildly involving the right A1 segment and proximal portion of the right A2. There is infundibulum along the origin of lenticulostriate artery trunks at the distal right internal carotid artery and the proximal right anterior cerebral artery A1 segment which collateralize to reconstitute the right middle cerebral artery. There is enlargement of the right recurrent artery of Heubner which supplies right sided lenticulostriate arteries to the right basal ganglia and also collateralizes to the right middle cerebral artery through these lenticulostriate arteries. The tortuous fusiform dilatation results in mild mass effect on the right uncus is unchanged. An anterior communicating artery is present. There are dilated pial vessels along the watershed zone between the right anterior middle cerebral arteries suggesting leptomeningeal collateral reconstitution of the right middle cerebral artery.There is a developmental venous anomaly present along the right thalamus.The left internal carotid artery is preserved in caliber and flow-related signal. The left anterior and middle cerebral arteries are preserved as well. The basilar artery is codominantly supplied by the vertebral arteries. The right posterior communicating artery is medium-sized. The left posterior communicating artery is very small. Anterior communicating artery is medium-sized. There is triplication of the anterior cerebral artery. The vertebral arteries are similar in size.
1.Fusiform aneurysmal dilatation of the distal ophthalmic and communicating segment of the right internal carotid artery with extension into the right A1 and proximal right A2 segment are stable compared with the prior exam.2.There is a redemonstration of occlusion of the right middle cerebral artery at its origin with collateral reconstitution through lenticulostriate arteries as well as well as leptomeningeal collaterals. This gives a unilateral moyamoya like picture.3.Several punctate left frontal T2/FLAIR periventricular and subcortical white matter lesions are nonspecific and unchanged.