Diagnosis: Unspecified disorder of the pituitary gland and its hypothalamic control. Subarachnoid hemorrhageClinical question: sellar mass, SAH, SDH, unilateral vision loss MRI of the brainThere are small foci of diffusion restriction along the territory of the right anterior choroidal artery including the uncus, internal capsule. There is a .punctate focus of diffusion restriction along the right ACA territory at the anterior aspect of the cingulate gyrus. There are a couple punctate foci of diffusion restriction along the left centrum semiovale..There is subdural blood present along the tentorium, falx and adjacent to the right frontal bone and right parietal bone. There is redemonstration of blood products within the sella and suprasellar cistern within the subarachnoid space.There is a hemorrhagic lesion along the sella and suprasellar cistern.The patient is status post transsphenoidal surgery. There is packing material within the posterior superior aspect of the nasal cavity. The visualized portions of the paranasal sinuses demonstrate some air-fluid levels in the maxillary sinuses and partial opacification of the sphenoid sinus as well as the posterior and middle ethmoid air cells. 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 are partially opacified. The visualized portions of the mastoid air cells are partially opacified. The visualized portions of the orbits are intact.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 associated narrowing of the ophthalmic segment of the right internal carotid artery associated with the above-described aneurysmal type lesion with approximately 70% stenosis. There is also some milder narrowing of the distal left internal carotid artery at the ophthalmic segment with approximately 40% narrowing of this vessel.There is a 2 mm x 2 mm sessile left cavernous internal carotid artery aneurysm directed laterally at the proximal portion of the horizontal portion of the cavernous segment.There is no evidence for cerebrovascular occlusion.The anterior communicating artery is identified. The posterior communicating arteries are not readily identified. The vertebral arteries are similar in size.There is extracranial origin of the PICA bilaterally.
1.Acute infarctions along portions of the right anterior choroidal artery territory with small/punctate infarctions at the right ACA territory and left centrum semiovale.2.The patients known pseudo aneurysm is not well demonstrated on this exam. Because it is slow filling a CTA or alternatively possibly a phase contrast MRA or MRV with contrast would be more sensitive to identifying it than an MRA3.There is 70% stenosis of the distal right internal carotid artery and mild narrowing of the left internal carotid artery along the respective ophthalmic segments. Please note that this is associated with a hypoplastic right A1 segment and nonvisualization of the right posterior communicating artery suggesting isolation of the right middle cerebral artery from the rest of the circulation.4.Subarachnoid and subdural hematomas 5.2 mm left cavernous internal carotid artery aneurysm.6.Status post transsphenoidal surgery with postoperative changes.