Infectious endocarditis, large vegetation on mitral valve, rule out septic embolism. Transient altered mental status. Multiple foci of restricted diffusion are seen involving the bilateral cerebral hemispheres as well as infratentorially including the bilateral cerebellar hemispheres. The relatively largest area of restricted diffusion is seen within the left cerebellar hemisphere in the left superior cerebellar artery territory. There is corresponding T2/FLAIR hyperintensity. Additional scattered foci of FLAIR hyperintensity in the periventricular and subcortical white matter are compatible with chronic small vessel ischemic changes. Tiny focus of susceptibility is seen in the left frontal subcortical white matter compatible with chronic microhemorrhage and probably present on prior MRI although study with motion degraded.There is advanced supra-and infratentorial global parenchymal volume loss. There is prominence of the ventricular system with T2 hyperintensity involving the periventricular white matter which remains unchanged from 8/14/2014 and suggestive of transependymal flow.No intracranial mass or mass-effect. No midline shift or downward herniation. Major flow-voids are preserved. Empty sella incidentally noted. There is moderate opacification of the left middle ear cavity and mastoid air cells.
1. Multiple (greater than 10) scattered supratentorial and infratentorial foci of restricted diffusion consistent with acute infarcts. These involve the bilateral anterior and posterior circulations and compatible with embolic disease. Largest of the infarcts involves the left cerebellar hemisphere. Given history of infectious endocarditis, may consider follow up study for development of abscess as clinically indicated. No findings to suggest abscess on the current non-contrast study.2. Advanced global parenchymal volume loss.3. Prominence of the ventricular system, possibly disproportional to the degree of volume loss, which may suggest component of chronic communicating hydrocephalus. Finding however is unchanged since 8/12/2014.4. Tiny focus of chronic microhemorrage in the left frontal lobe, which was probably present on prior study although study was motion degraded. No acute infarct within the region to suggest hemorrhagic transformation. Dr. Ali discussed findings with Radovanovic at 1450 hrs on 2/6/2015.