Left-sided hemiparesis. Evaluate for stroke. The patient was unable to hold still for the examination. Multiple sequences were repeated.Brain MRI without and with intravenous contrast:The right basal ganglia infarct is now associated with significant susceptibility effect indicating hemorrhagic conversion. There is surrounding diffusion restriction which involves the head of the right caudate nucleus as well as the right inferior and middle frontal gyri. There are other foci of diffusion restriction involving the right supramarginal gyrus as well. These are in the distribution of the middle cerebral arteries (including the lateral lenticulostriate arteries). There is minimal cortical diffusion restriction in the right occipital lobe along the semilunar sulcus. There are tiny foci of contrast enhancement along the inferior aspect of the infarct. There is also a tiny focus of contrast enhancement in the region of the supramarginal and occipital infarcts. The basal ganglia infarct and the associated hemorrhage result in mild to moderate mass effect compressing the frontal horn and body of the right lateral ventricle and causing mild midline shift. The overlying insula is also compressed as well as the underlying internal capsule and thalamus.. The hemorrhage does extend into the ventricular system with there is dependent blood in the occipital horns of the lateral ventricles. There is also mild dilatation of the remainder of the ventricular system compared to the previous examination. Mastoid air cells are clear. Paranasal sinuses are clear. There is a previous blowout fracture along the medial wall of left orbit associated with minimal enophthalmus. The orbits are otherwise normal.Cranial MRA without contrast:The right internal carotid artery is slightly smaller than the left but shows preserved flow. This likely congenital given the asymmetrically smaller right A1 segment. There is minimal irregularity of the right M1 segment, from which prominent lateral lenticulostriate arteries arise. The appearance might be reactive to the adjacent infarct/hemorrhage. The remainder of the middle cerebral arteries is normal. Associated with the above-described small right A1 segment, a well-developed anterior communicating artery provides preserved flow to the right A2 and more downstream segments of the right anterior cerebral artery. The posterior circulation is normal accounting for the basilar artery being dominantly supplied by the left vertebral artery. Neck MRA with contrast:The cervical common and internal carotid arteries show no significant luminal narrowing. There is focal attenuation of signal related to the right vertebral artery at its origin which may relate to artifact. The remainder of the right vertebral artery is smaller than the left which can be congenital or from ostial narrowing.
1.Hemorrhagic transformation of the right basal ganglia infarct with intraventricular extension of the hemorrhage. The infarct is associated with mass effect as described above.2.Contrast enhancement foci associated with a basal ganglia and cortical infarcts probably reflect their early subacute nature.3.Relatively unremarkable cranial MR angiography accounting for the infarct/hemorrhage reactive change along the right lateral lenticulostriate arteries.4.No significant cervical carotid stenoocclusive disease.Dr. Qandeel has discussed the hemorrhagic conversion of the infarct and the associated intraventricular hemorrhage with the neurology resident on service (Dr. Del Brutto Andrade) at noon on the day of the examination.