Clinical question: Evaluate for structural lesion, ischemia. Signs and symptoms: Comatose, diskitis and flexor positioning. Nonenhanced brain MRI:Diffusion-weighted images are severely degraded due to extensive artifact from patient's significant intracranial hemorrhage.A large irregularly shaped dissecting hematoma in the left basal ganglia and thalamus is again identified. Hematoma measures approximately 40 x 40 2-mm in its largest transaxial dimensions. There is extensive surrounding vasogenic edema and constellation of findings results in significant rightward deviation of midline of approximately 12.5 mm. There is inferior extension of vasogenic edema into the left cerebral peduncle, left pons as well as left quadrigeminal plate.There is extensive extension of hemorrhage into the ventricular system with large CSF/blood layering in dependent bilateral occipital horns (left greater than right) without significant change since prior exam. There is evidence of resultant ventriculomegaly with a uniform thick bands of flair hyperintensity surrounding the ventricles suggestive of trans-ependymal exiting off CSF. Possibility of overlapping chronic small vessel ischemic strokes however cannot be entirely excluded. The cortical sulci remain small likely secondary to increased intracranial pressure. The basal cistern remains patent and without evidence of herniation. A right frontal approach ventricular catheter traverses the right frontal lobe, traverses the right lateral ventricle and the tip of the catheter within the hematoma and likely within the third ventricle. The signal void of all major intracranial arterial branches are identified.Nonenhanced brain MRA: Right internal carotid artery is patent across the skull base and in its supraclinoid segment. Right middle cerebral artery and its branches are patent. Mild vascular irregularity of right M1 could represent atherosclerotic disease however without vascular lumen compromise. There is absence of the right A1 representing an anatomical variation of hypoplasia. Bilateral anterior cerebral arteries however are filled via a larger left A1.Patent and unremarkable left internal carotid artery across the skull base and in the supraclinoid segment. Unremarkable left anterior and middle cerebral arteries and their branches.Unremarkable dominant right vertebral artery, right pica, basilar artery, superior cerebellar and bilateral posterior cerebral arteries. Short segmental moderate vascular lumen compromise of the perimesencephalic segment of the left posterior cerebral artery as result of atherosclerotic disease is noted. Distal branches however remain patent. A hypoplastic left vertebral artery is visualized only in its distal segment on reformatted images. The left vertebral artery, left pica however is well identified and patent on source images.Examination demonstrates no detectable increased vascularity within the hematoma to suggest a vascular malformation or aneurysm as a cause of hemorrhage.
1.Large dissecting hematoma in the left basal ganglia/thalamus measuring maximum although 40 times 40 mm in transaxial dimensions.2.Extensive surrounding vasogenic edema and associated mass-effect resulting 12.5-mm deviation of midline to the right.3.Extensive intraventricular hemorrhage, supratentorial ventriculomegaly and CSF/blood layering in dependent occipital horns.4.A band of flair hyperintensity surrounding the ventricular system suggestive of transependymal exudate of CSF.5.Effaced cortical sulci over patent basal cistern.6.MRA of intracranial circulation demonstrate patency of all the intracranial vasculature. There is a short segmental moderate vascular lumen compromise of the perimesencephalic segment of left posterior cerebral artery representing atherosclerotic disease. The distal branches of this vessel however remain patent. There is no detectable increased vascularity or aneurysm within the left hemispheric hematoma.