Left-sided weakness and slurred speech. Rule out ischemic stroke. Brain MRI without contrast:There is focal diffusion restriction along the posterior limb of the right internal capsule, correlating with the focal hypoattenuation on the companion CT scan. The remainder of the moderate to extensive cerebral white-matter abnormalities show no associated diffusion restriction. Milder but otherwise similar white-matter change is present in the brainstem and along the middle cerebellar peduncles. There is no susceptibility artifact to indicate intracranial hemorrhage. Predominantly central brain volume loss resulting in ventricular dilatation has not changed. There is no midline shift or brain herniation. Major intracranial vascular flow voids are preserved, reflecting gross patency.There is very minimal mucosal thickening in the maxillary and ethmoid sinuses. There are changes of previous bilateral cataract surgery. There is no destructive skull lesion.CRANIAL MRA WITHOUT CONTRAST:The intracranial internal carotid arteries show preserved flow-related signal and caliber. Similarly, the paired anterior and middle cerebral arteries and their major branches are preserved. The basilar artery is codominantly supplied by the vertebral arteries which also show preserved flow-related signal and caliber. The posterior cerebral arteries and their major branches are preserved as well. Of note, the right posterior communicating artery is well-developed. A smaller left posterior communicating artery is also present. Anterior communicating artery is also present. There is no aneurysm.NECK MRA WITH CONTRAST:The left common carotid artery arises from a common trunk with the right brachiocephalic artery, which is a common normal variation. The common carotid and the cervical internal carotid arteries show no significant stenosis. There is also no significant ostial narrowing. The vertebral arteries are slightly nonuniform in their caliber, most pronounced in the lower V2 segments, which is favored to be artifactual given high positioning of shoulders. There is no significant stenosis.
1.Focal diffusion restriction along the posterior limb of the right internal capsule is compatible with an acute ischemic stroke.2.The remainder of the moderate to extensive cerebral white-matter and right thalamic abnormalities are not diffusion restricted, reflecting chronicity of ischemic changes.3.Cranial and cervical MR angiography show no flow limiting stenosis.