53-year-old with aphasia and left-sided weakness. Evaluate for ischemia or hemorrhagic conversion of chronic left PICA infarct. MRI brain:There is cystic encephalomalacia of the inferior left cerebellar hemisphere compatible with a chronic infarct. The adjacent remaining cerebellar white matter has increased T2 signal compatible with gliosis. There are punctate foci along the border of the infarcts that have restricted diffusion indicating some foci of acute to subacute ischemia. No evidence of hemorrhagic conversion.Numerous additional foci of subcortical and periventricular white matter T2 hyperintensity compatible with chronic small vessel ischemic changes.There is no evidence of intracranial hemorrhage, mass or edema. The ventricles and basal cisterns are normal in size and configuration. The paranasal sinuses are clear. There is trace opacification of the mastoid air cells bilaterally. The orbits are unremarkable.MRA head:Mild atherosclerotic irregularity of the cavernous internal carotid arteries. There is a complete circle of Willis, but the right P-comm is diminutive. Partial fetal morphology of the left posterior cerebral artery. Left dominant vertebrobasilar system. The left PICA is markedly attenuated. No significant intracranial aneurysm. No additional sites of high-grade steno-occlusive disease.MRA neck:Conventional arch anatomy. The origins of the carotid and vertebral arteries are widely patent. The carotid systems and vertebral arteries are normal in caliber and contour throughout.
1. 2 punctate foci of acute to subacute ischemia in the left cerebellar lobe adjacent to a large chronic left PICA infarct.2. No evidence of intracranial hemorrhage as clinically queried.3. Diminutive left PICA. Otherwise no high-grade steno-occlusive disease in the head and neck. No intracranial arterial aneurysm.