Facial weakness [R29.810], Reason for Study: ^Reason: L facial droop History: L facial droop Brain MRIThere is restricted diffusion on the right side basal ganglia and right caudate nucleus head. These lesions are mixed with T2/FLAIR high signal intensity lesions thus indicating acute/subacute ischemic infarct.On gradient echo images, especially on the lateral aspect of the lesion show subtle susceptibility artifacts indicating possible hemorrhagic transformation. However, this lesion shows in close proximity to the brain show right side middle thalamic vein, thus could represent venous flow related artifacts.There is linear subcortical FLAIR high signal intensity lesions on the right side inferior parietal lobule (series 1101, image 23) without showing restricted diffusion which indicate age indeterminate likely chronic ischemic infarction.Subtle increased signal intensity of the right central sulcus on FLAIR (series 1101, image 26). However, since this finding is not associated with restricted diffusion or evidence of hemorrhage but shows prominent tubular structure on Gradient echo (series 1001, image 90), this finding could represent an artifacts related to relatively slow cortical venous flow. The ventricles, sulci and cisterns are symmetric and unremarkable. There is no mass, mass effect, edema, midline shift, intra or extra-axial fluid collection/hemorrhage. The midline structures and cranial-cervical junction are normal. The paranasal sinuses and mastoid air cells are clear.Brain MRA3D time of flight MOTSA MRA brain images with maximum intensity projections of the anterior/posterior intracranial circulation demonstrate complete occlusion of the right MCA at the point of right internal carotid artery intracranial bifurcation. An enteric indicating artery is patent bilateral posterior communicating artery are also patent.Vertebrobasilar system as well as left internal carotid artery, left MCA and bilateral anterior cerebral arteries appear to be normal.
1. Constellation of above findings indicate right MCA complete occlusion related multistage ischemic infarctions with acute ischemic infarction involving right basal ganglia.2. Possibility of focal hemorrhagic transformation cannot completely excluded especially lateral aspect of the acute ischemic infarction.3. Cortical venous slow flow and chronic subcortical ischemic infarction may indicate possible low perfusion status. Thus, if clinically indicated, CT perfusion study can be considered for further physiologic imaging evaluation. 