Reason: PRES History: evaluate progression MRI of the brainpatchy foci of T2 and flair signal hyperintensity are present subtle in the left cerebellar hemisphere, more extensive than the right occipital lobe and adjacent to right posterior temporal lobe, small region in the left occipital pole, right thalamus, bilateral frontal lobes and watershed distribution in the Frommel and parietal lobes right more than left. There are associated mild degree of periventricular white matter lesions compared these findings were present on the previous exam appeared in the extent of these lesions is not clear to have changed tiny significant degree. On the associated susceptibility weighted imaging there is no microhemorrhage appreciated associated with these lesions. On the ADC maps there is very little evidence for diffusion restriction perhaps a little bit in the right subcortical white matter adjacent to the precentral and central gyrus, however, significantly less than the T2 and flair signal abnormalities. Postcontrast imaging demonstrates small foci of patchy enhancement along the cortex of the frontal lobes bilaterally but right more than left. The enhancement is significantly less than the T2 and FLAIR abnormality. Additionally there appears to be intravascular enhancement present in some subtle leptomeningeal enhancement adjacent to the left cerebellar hemisphere and right posterior and inferior aspect of the temporal lobe and adjacent occipital lobe . Overall this pattern is not changed substantially when compared to the prior exam.No abnormal mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.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.Unopposed contras SPGR T1 images only there is a tubular enhancing structure which projects over the brainstem. It is suspected to represent artifact as it is not seen on any of the pulse sequences other than this one. It likely represents misregistration from the left vertebral artery.The visualized portions of the paranasal sinuses demonstrate mucosal thickening in the maxillary sinuses mainly in the sphenoid sinuses. The visualized portions of the mastoid air cells are partially opacified. The visualized portions of the orbits are intact.MRA brain: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.There is no evidence for intracranial aneurysm or cerebrovascular occlusion.The anterior communicating artery is identified. The posterior communicating arteries are not readily identified. The vertebral arteries are asymmetric left larger than right.There is extracranial origin of the right and left posterior inferior cerebellar artery.
1.This examination of the brain has not change substantially when compared to the previous exam. There are predominantly cortical but also adjacent white matter patchy lesions involving supratentorial brain as well as left cerebellar hemisphere and right thalamus as detailed above. There is some associated leptomeningeal disease. Although one possibility is that these findings can be explained on the basis of posterior reversible encephalopathy syndrome, the interval lack of change may suggest otherwise and the imply a different etiology. Considerations may include encephalitis as well as vasculitis.2.No evidence for intracranial aneurysm or cerebrovascular occlusion or stenosis. 3.Findings were discussed with Dr Goldenberg.