Evaluate for right thalamic bleed versus calcification. Brain MRI: There is a punctate hemorrhage in the right thalamus with mild surrounding vasogenic edema. There are numerous other supratentorial and infratentorial punctate foci of susceptibility effect. There is a punctate focus of restricted diffusion in the right peritrigonal white matter with corresponding high T2 signal. There are subcentimeter defects in the pons and left cerebellar hemisphere. There is no midline shift. There is a tortuous and mildly ectatic vertebrobasilar system that impresses upon the pons.Brain MRA: There is no evidence of significant steno-occlusive lesions of the circle of Willis or aneurysms.Neck MRA: There is no definite evidence of significant steno-occlusive lesions, within the limits of patient motion artifact.
1. Punctate acute hemorrhage in the right thalamus superimposed upon a background of extensive chronic microhemorrhages, likely hypertensive in nature. 2. Acute punctate infarct in the right peritrigonal white matter superimposed upon a background of extensive chronic hypertensive encephalopathy or small vessel ischemic disease and chronic lacunar infarcts.3. No definite evidence of significant steno-occlusive lesions in the major head and neck arteries, although the neck images are degraded by patient motion artifact. A Doppler ultrasound may be useful for further evaluation if clinically warranted. 4. Vertebrobasilar dolichoectasia that impresses upon the pons.