Myoclonic encephalopathy: worsening myoclonus. Brain MRI: There is no evidence of intracranial hemorrhage, mass, or acute infarct. There is a small area of encephalomalacia in the left occipital lobe. There is diffuse cerebral white matter T2 hyperintensity bilaterally. There are a few scattered punctate foci of susceptibility effect in the bilateral cerebral hemispheres. There is mild diffuse cerebral and cerebellar volume loss, especially posteriorly. There is no midline shift or herniation. The major cerebral flow voids are intact. The skull and scalp soft tissues are grossly unremarkable. There are bilateral lens implants. There are secretions in the left frontoethmoid recess.Brain MRA: There is an unchanged 5 mm diameter saccular aneurysm at the right middle cerebral artery bifurcation with a 3 mm wide neck. There is also an unchanged 6 mm long basilar tip aneurysm with a 3 mm wide neck and a mildly irregular contour. There is no evidence of significant steno-occlusive lesions.Neck MRA: There is an apparent high grade stenosis at the origin of the right vertebral artery. Otherwise, there is no evidence of significant steno-occlusive lesions elsewhere in the major neck arteries. There is a right thyroid nodule that measures up to at least 45 mm.
1. Small chronic left occipital lobe infarct, but no evidence of acute acute infarct. Nonspecific diffuse cerebral white matter T2 hyperintensity bilaterally may represent chronic small vessel ischemic disease and scattered punctate foci of susceptibility effect in the bilateral cerebral hemispheres may represent chronic microhemorrhages, perhaps related to amyloid angiopathy. 2. Mild diffuse cerebral and cerebellar volume loss, especially posteriorly, may be a manifestation of myoclonic encephalopathy.3. Unchanged subcentimeter right middle cerebral artery and basilar tip aneurysms.4. Apparent high grade stenosis at the origin of the right vertebral artery. Otherwise, no evidence of significant steno-occlusive lesions in the head and neck arteries.5. A nonspecific right thyroid nodule measures up to at least 45 mm. Thyroid ultrasound may be useful for further evaluation.