Diagnosis: Syncope and collapseClinical question: syncopal episode; h/o prior ischemic strokeSigns and Symptoms: passing out episodes x 2 MRI cervical spine:The cervical vertebral bodies are appropriate in overall alignment and height. The cervical spinal cord has normal signal characteristics and overall morphology. There is multilevel disc desiccation present.At C2-3 there is no significant compromise to the spinal canal. There is bilateral facet hypertrophy present at this level - right more than left - with encroachment of right-sided exiting nerve roots.At C3-4 there is no significant compromise to the spinal canal. There is bilateral facet hypertrophy present at this level with encroachment of left-sided exiting nerve roots.At C4-5 there is no significant compromise to the spinal canal. There is a left paramedian disc protrusion present at this level as well as bilateral facet hypertrophy and encroachment of the exiting nerve roots bilaterally left worse than rightAt C5-6 there is no significant compromise to the spinal canal. There is a diffuse disc bulge present at this level associated with small uncovertebral osteophytes and narrowing of the neural foramina bilaterally with encroachment of exiting nerve roots. There is partial effacement of spinal fluid ventral to the spinal cord at this level.At C6-7 there is no significant compromise to the spinal canal or neural foramina. There are some small endplate and uncovertebral osteophytes present at this level with mild encroachment of the exiting nerve roots within the neural foramina on the right side.At C7-T1 there is no significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact.MRI of the brainNo diffusion weighted abnormalities are appreciated.There is a mild degree of periventricular and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images.There are T2 and FLAIR hyperintense lesions present in the internal capsules and basal ganglia as well as the brainstem and thalami. On susceptibility weighted imaging there are punctate foci of low signal in the thalami bilaterally as well as the pons and cerebellum and to a lesser degree basal ganglia. This has not changed substantially since the prior exam.The CSF spaces are appropriate for the patient's stated age with no midline shift. 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 mucosal thickening in the paranasal sinuses.. The visualized portions of the mastoid air cells are clear. 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 no evidence for intracranial aneurysm or cerebrovascular occlusion.The anterior communicating artery is identified and is medium size. The right posterior communicating artery is relatively small but can be identified. The left posterior cerebral artery has fetal origin. The vertebral arteries are similar in size.MRA 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. There is no significant stenosis along the course of the vertebral arteries identified to the extent of visualization. The origins of the vertebral arteries are partially obscured due to artifacts..
1.No evidence for intracranial aneurysm.2.No evidence for intracranial or extracranial cervicocerebral vascular occlusive disease.3.Periventricular and subcortical white matter changes of a mild degree are nonspecific. At this age they are most likely vascular related. 4.There are multiple microhemorrhages present predominantly distributed in the thalami and brainstem and cerebellum which are in a pattern compatible with hypertension. This has not changed substantially since the prior exam.5.There are multilevel degenerative changes present in the cervical spine without evidence for spinal stenosis. There is encroachment of exiting nerve roots within the neural foramina at multiple levels as detailed above