Clinical question: 5 days of R hand weakness and dysmetria, eval for signs of CVA vs posterior circulation defectSigns and Symptoms: R hand weakness, R hand dysmetria, abnormal coordinationComments: Clinical question to be answered (appropriate, detailed history MUST be included in order to assure exam appropriateness \T\ accuracy of interpretation):->5 days of R hand weakness and dysmetria, eval for signs of CVA vs posterior circulation defect | Signs and Symptoms:->R hand weakness, R hand dysmetria, abnormal coordination MRI of the brainA focus of diffusion restriction is present in the left centrum semiovaleThere is a mild degree of periventricular and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images.The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal enhancing 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.The visualized portions of the paranasal sinuses are clear. The visualized portions of the mastoid air cells are clear. 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 and is medium size. The posterior communicating arteries are intact but very small. The right vertebral artery significantly smaller than the left vertebral artery.MRA neck:There is opacification of the aortic arch, great vessels from the aortic arch and carotid arteries and vertebral arteries. There is no stenosis identified of the great vessels from the aortic arch. On the basis of NASCET criteria there is no significant stenosis at the carotid bifurcations. The right vertebral artery significantly smaller than the left vertebral artery.
1.There is acute infarction present in the left centrum semiovale. This corresponds to the left middle cerebral artery territory2.Periventricular and subcortical white matter changes of a mild degree are nonspecific. At this age they are most likely vascular related. 3.Although there is no convincing evidence for dissection, the dissection protocol was not followed. A small dissection could be overlooked as a result.4.The right vertebral artery appears to be small on a congenital or on the basis of chronic severe occlusive disease.