 BRAIN: There are stable patchy foci of T2 hyperintensity within the thalami, anterolaterally on the left and posterior medially on the right. There are also symmetric rounded foci of T2 hyperintensity within the medullary olives which are slightly more prominent, although this apparent change could reflect technical differences. There is no associated decreased diffusion or enhancement. Punctate symmetric foci of T2 hyperintensity are seen on the FLAIR sequences within the bilateral insula that were not seen on the prior exam. These are present on axial, coronal and sagittal FLAIR acquisitions, but are not confirmed on other sequences. Questioned signal abnormality in the caudate nuclei and corticospinal tracts on the prior exam is not duplicated and may have been artifactual. There is a right frontal lobe developmental venous anomaly. There is no evidence of intracranial hemorrhage or acute infarct. The ventricles and basal cisterns are normal in size and configuration. There is no midline shift or herniation. The major cerebral flow voids are intact. Sphenoid sinus inflammatory disease is seen.PITUITARY: There is a normal pituitary height for age. The posterior pituitary bright spot is present. The infundibulum is slightly deviated to the left, although, there is no evidence for pituitary or suprasellar mass. The optic chiasm, cavernous sinuses and intracranial portions of the optic nerves are normal in appearance.MR SPECTROSCOPY: A spectrum obtained over the medullary olives demonstrates markedly diminished NAA and perhaps trace lactate. Spectra obtained over both thalami demonstrate modest reductions in NAA but no significant lipid or lactate. Spectra obtained over normal appearing grey and white matter show moderate reductions in NAA (particularly in grey matter), but again no significant lipid or lactate.
1. Signal abnormality involving the bilateral thalami and medullary olives persists, and is unchanged in the thalami and unchanged or at most mildly progressed in the olives. The spectroscopic pattern of these lesions indicates neuronal injury or loss, and in addition, there may be trace lactate in the olives. Of note, normal appearing grey and white matter also show reduced levels of NAA, which would suggest a global or systemic phenomenon. While not diagnostic of any particular entity, the spectroscopic pattern, along with conventional imaging findings, would be compatible with an inherited metabolic deficiency, perhaps mitochondrial in nature.2. Normal pituitary MRI. 