79 years Female (DOB:3/12/1936)Reason: stroke evaluation History: L sided clumsiness/weaknessPROVIDER/ATTENDING NAME: MURRAY J KEENE MURRAY J KEENE The CSF spaces are appropriate for the patient's stated age with no midline shift. There is a focus of encephalomalacia involving the medial aspect of the left occipital lobe which involves left lingual gyrus and left cuneus and part of the left fusiform gyrus. It is associated with ex vacuo effect along the left lateral ventricle.There is no evidence for diffusion restriction on the current exam.A punctate hypointense focus is present along the inferior aspect and posterior aspect of the right thalamus. There are punctate foci of signal hyperintensity on T2 imaging in the right thalamus and the basal ganglia bilaterallyThere is a mild degree of periventricular and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images.No abnormal 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 demonstrate minor opacities. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact. The eyeball lenses are thin.
1.There is no evidence for acute cerebral ischemic infarction.2.There is encephalomalacia involving much of the left occipital lobe which is probably related to prior vascular event.3.Small lesions in the basal ganglia and right thalamus are likely related to prior lacunar infarcts.4.Findings suggest a microhemorrhage in the right thalamus which in isolation is of unknown clinical significance.5.Periventricular and subcortical white matter lesions of a mild degree are nonspecific. At this age they are most likely vascular related. 