Clinical question: frontotemporal atrophy, question of vascular etiologySigns and Symptoms: PPAComments: Paired with MRI. | MRI of the brainNo diffusion weighted abnormalities are appreciated.There is a moderate degree of periventricular and subcortical confluent hyperintense white matter lesions present identified on the FLAIR and T2 images. This is a clear progression from the 12/14/2010 exam.There is loss of left hemispheric white matter mantle with enlargement of the left lateral ventricle. There is encephalomalacia present along the left anterior temporal lobe. There is also some encephalomalacia along the left middle frontal gyrus This is a clear progression from the 12/14/2010 exam.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 demonstrate a mucous retention cyst in the left maxillary sinus. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact.No abnormal enhancing mass lesions are appreciated intracranially.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. The vertebral arteries are similar in size. The left posterior communicating artery is almost the same size as the left P1 segment. The right posterior communicating artery is very small. The left A1 segment is larger than the right A1 segment. The anterior communicating artery is relatively small. The right vertebral artery is larger than the left vertebral arteryMRA 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. Several centimeters distal to the carotid bifurcation on the left side the left internal carotid artery appears to smoothly narrow in the AP direction with approximately 70% stenosis.There is no significant stenosis along the course of the vertebral arteries. The right vertebral artery is larger than the left vertebral artery.The left lobe of the thyroid appears significantly enlarged and heterogeneous.
1.Since the prior examination there has been marked progression of loss of the left hemispheric white matter mantle and progression of periventricular white matter lesions bilaterally but mostly on the left side. Additionally since 12/2010 there is new encephalomalacia in the left anterior temporal lobe and left middle frontal gyrus. Differential considerations include vascular related process (see impression #2) as well as neurodegenerative process .2.There is 70% stenosis with smooth in narrowing of the left internal carotid artery distal to the bifurcation. One possibility is that this is related to a dissection of the left internal carotid artery with interval healing. This could also explain the intracranial findings which are ipsilateral to this lesion.