 There is an area of abnormal signal within the right paracentral lobule which demonstrates increased signal on DWI images, decreased signal on ADC images, and increased signal on T2-weighted images compatible with a subacute ischemic infarction. SWI demonstrate several patchy areas of susceptibility within this area compatible with associated microhemorrhage. There is mild local edema and sulcal effacement without significant mass effect. There is an additional punctate focus of restricted diffusion within the right post central gyrus. This area demonstrates associated only mildly increased T2 signal again suggesting subacute infarct, likely more recent than the infarct in the paracentral lobule. It is difficult to assess for associated hemorrhage in this area due to motion artifact on the GRE images.There is a large area of encephalomalacia involving the right parietal, posterior frontal, and posterior temporal lobes corresponding to the infarct seen on 8/31/2010 examination. Punctate and confluent foci of increased T2/FLAIR signal within the periventricular and subcortical white matter are compatible with chronic small vessel ischemic changes. Volume loss involving the right cerebral peduncle is compatible with expected Wallerian degeneration related to right chronic MCA distribution infarctionBurr holes are again seen in the posterior calvarium within an associated underlying focus of encephalomalacia in the right precuneus extending into the cuneus. There is mild ex vacuo dilatation of the right lateral ventricle without evidence of hydrocephalus. A partially empty sella is noted. There is patchy mucosal thickening within the maxillary sinuses, ethmoid air cells, and sphenoid sinuses.No evidence of intracranial mass or mass effect. No pathologic midline shift or herniation. The flow voids in the major intracranial vascular structures are grossly intact except for the right MCA due to chronic occlusion.
1.Multifocal, subacute ischemic infarction with small amount of associated hemorrhage involving the right paracentral lobule and right post-central gyrus. Given distribution, associated hemorrhage, and possibility of varying ages, venous infarct is a possibility. Recommend dedicated MRV to assess for venous sinus thrombosis.2.Chronic infarction/encephalomalacia involving the right parietal, posterior frontal, and posterior temporal lobes.3.Moderate chronic small vessel ischemic changes.Findings discussed with PULIMI, SANDEEP by Dr. David Kromrey at 9:30 a.m. on 9/9/2015. 