Clinical question: Pontine hemorrhagic stroke. Signs and symptoms: Pontine hemorrhagic stroke. Nonenhanced brain MRI:Examination demonstrates a previously known large acute hemorrhagic stroke of the pons with surrounding edema which mildly extends into the bilateral middle cerebellar peduncles. Findings results in expansion of the pons and with subtle mass effect on the fourth ventricle which remains widely patent. There is also tiny amount of intraventricular spread of hemorrhage visible in the dependent bilateral occipital horns on susceptibility MRI images.Images through supratentorial space demonstrate fairly extensive periventricular and subcortical and to a lesser degree in the right basal ganglia foci of FLAIR and T2 hyperintensity suggestive of extensive chronic small vessel ischemic strokes. This findings are associated with multiple tiny foci of susceptibility signal changes consistent with chronic microhemorrhages. Susceptibility signal changes are also present in bilateral cerebellar hemispheres however without convincing evidence of associated FLAIR hyperintensity.There is mild prominence of supratentorial ventricular system for age and consistent with ex vacuo dilatation secondary to chronic small vessel ischemic strokes. This appearance is similar to prior head CT studies.The CSF cisterns remain widely patent and midline is maintained.There is no evidence of cortical signal abnormality to suggest chronic or acute cortical ischemic strokes.Signal void of major intracranial arterial branches are present. Signal intensity of the intracranial venous sinuses are unremarkable.Unremarkable calvarium, soft tissues of the scalp, orbits, paranasal sinuses and mastoid air cells.The unenhanced brain MRA:Patent bilateral vertebral arteries which are symmetrical in size. Patent basilar artery and its distal branches.Patent right internal carotid artery, right anterior and middle cerebral arteries. Mild atherosclerotic disease of the distal branches are identified.Patent and unremarkable left internal carotid artery, left anterior and middle cerebral arteries. Mild distal vessel atherosclerotic disease is noted.
1.Acute hemorrhagic stroke of the pons with resultant mild expansion of the pons and subtle mass effect as detailed.2.Extensive supratentorial chronic small vessel ischemic strokes.3.Numerous foci of susceptibility signal changes in supra and infratentorial tentorial parenchyma within and beyond the regions of chronic small vessel ischemic strokes consistent with chronic microhemorrhages.4.Mild supratentorial ventriculomegaly as result of underlying parenchymal volume loss.5.Nonenhanced brain MRA demonstrate patency of all major arterial branches. Atherosclerotic disease of distal branches are however present.