 MRI BRAIN: There is large area of restricted diffusion involving the majority of the left cerebral hemisphere, in the left MCA and the left PCA territories. There is diffuse cytotoxic edema in left cerebral hemisphere associated with T2/FLAIR hyperintensity and sulcal effacement. There are cortical foci of susceptibility in the infarcted left cerebral gyri, probably related to petechial hemorrhage. There is rightward subfalcine herniation of approximately 7 mm. The left lateral ventricle is partially effaced and there is prominence of the right temporal horn and the trigone, concerning for early trapping. There is a very early left uncal herniation.Additional foci of restricted diffusion are seen in the right pons, right globus pallidus, right midbrain, left cerebellum, and the right occipital white matter with diffuse confluent T2/FLAIR hyperintensity in the brainstem especially ventrally.There is symmetric bilateral increased T1 signal in the caudate nuclei and in the putamen bilaterally with associated susceptibility, concerning for mineralization. There is no surrounding FLAIR abnormality to suggest vasogenic edema.There is fluid in the ethmoids and in the left sphenoid sinus. Air-fluid level noted in the left maxillary sinus. Fluid is seen in the right maxillary sinus. Fluid is seen in the mastoids, left more than the right. There is a diffuse amount of fluid in the nasal cavity.There is cavum septum pellucidum et vergae, normal variant.MRA BRAIN:The left ICA is slightly larger than the right as there is a hypoplastic right A1. The flow-related enhancement in the distal left M1 proximal to the trifurcation is slightly attenuated, probably representing a partial thrombus. The distal left MCA branches are attenuated as compared to the right.There is mild focal narrowing of the left M1 origin.The right V4 segment is irregular with a severe focal narrowing proximal to its midportion. The V4 segment of the left vertebral artery distal to the PICA is developmentally diminutive.MRA NECK:Evaluation limited due to lack of contrast. The right vertebral artery is diminutive, with suboptimal flow-related enhancement distally.Note is made of bovine aortic arch, normal variant. There are apparent irregularities of the distal internal carotid arteries at the skull base, which are probably artifactual. Underlying pathology cannot be excluded.
1. Extensive acute infarct involving the left MCA and PCA territories, although left deep grey nuclei are spared.2. The flow in the distal left M1 is severely attenuated, which may represent a partial thrombus. The distal branches of the left MCA are severely attenuated, as compared to the right, which may relate to slow flow.3. Severely narrowed right V4 segment proximal to its midportion, and nondominant cervical right vertebral artery not well visualized distally.4. There is symmetric bilateral increased T1 signal in the caudate nuclei and globus pallidi bilaterally with associated susceptibility, consistent with mineralization. Toxic or metabolic abnormalities are in the differential.