Hemangioma of intracranial structures [228.02], Reason for Study: ^Reason: possible pontine infarct History: pt not waking up Brain MRIInterval near total excision of the left tegmentum cavernous malformation. While the area of susceptibility effect at the resection bed is slightly larger than the original resected cavernous malformation (measuring 14 mm in transverse now compared to 11 mm previously), this does not been certainly reflect actual expansion especially given the lack of significant change in the minimal rightward deviation of the aqueduct of Sylvius. Just anterior to the area of susceptibility effect related to the resection bed of the cavernous malformation, there is a focal diffusion restriction on the left side of midbrain anterior to aqueduct and extends anteriorly to the region of the mesial aspect of the left side red nucleus and just proximal to the left substantia nigra (series 400, image 13/32). These findings are associated with edema in the midbrain which is new compared to the baseline examinationThere is also linear tract-like susceptibility abnormality in the posterior aspect of the left superior/mid temporal lobe which was not present on the preoperative images and therefore most likely procedure related. Cervical MR angiography: 3D MRA neck post-gadolinium images with maximum intensity projections of the cervical vasculature demonstrate normal flow enhancement in a normal aortic arch origin of the right brachiocephalic, left common carotid, and left subclavian arteries. The right vertebral artery is small throughout its course, most probably congential. Otherwise, there is normal flow enhancement through the bilateral common carotid, carotid bifurcations, internal/external carotid, and vertebral arteries. Cranial MR Venography:3D MRV brain post-gadolinium with maximum intensity projections of the superficial/deep intracranial venous drainage demonstrate normal flow enhancement in the superior sagittal sinus, transverse sinuses, sigmoid sinuses, internal cerebral veins, vein of Galen and straight sinus. The inferior sagittal sinus is not visualized but this was not changed since the baseline examination and is likely a normal variation of very small or absent inferior sagittal sinus.Cervical spine MRI:The cranial-cervical junction is normal. There is straightening of the normal cervical lordosis which may reflect patient position. The cervical spine alignment is otherwise anatomic. The vertebral body height is preserved. The bone marrow and end plates demonstrate a normal MR appearance. The signal of the visualized cord is normal. The epidural space, thecal sac, and spinal cord are preserved with no evidence of spinal canal/neural foraminal narrowing or myelopathy. The intervertebral discs are notable mild loss T2 intensity and height at C5-C6 which is associated with disc-osteophyte complex mildly narrowing the spinal canal but not touching or displacing the cord. The height and T2 signal are preserved at the other discs. The paraspinal soft tissues are notable for mild edema surrounding the intubated airway which is nonspecific.Degenerative changes are specified by the intervertebral level as follows: C2-C3: no neuroforaminal narrowing or spinal stenosis. C3-C4: no neuroforaminal narrowing or spinal stenosis. C4-C5: no neuroforaminal narrowing or spinal stenosis. C5-C6: Shallow disc-osteophyte complex is slightly more prominent on the right and causes mild spinal canal narrowing. Uncovertebral proliferative changes slightly more pronounced on the left causing minimal left neural foraminal narrowing. C6-C7: no neuroforaminal narrowing or spinal stenosis. C7-T1: no neuroforaminal narrowing or spinal stenosis.
1.Blood products at the resected cavernous malformation in the mid brain tegmentum is likely to be residual blood products of the cavernous malformation. 2.New edema has developed around the resection bed along with small focus of diffusion restriction which may represent tiny midbrain infarct.3.Hemorrhagic tract is present in the posterior superior left temporal lobe and most likely procedure related as described above.4.Right frontal ventriculostomy has been placed with its tip near the right foramen of Monro. Ventricle size is stable.5.The cranial and cervical MR angiography as well as cranial MR venography show no significant abnormalities.6.Cervical spine shows mild degenerative C5-C6 osteophyte complex but no significant spinal canal or foraminal narrowing.Dr. Monther Qandeel discussed the above findings over the phone with the Neuro ICU resident Dr. Robin a. Buerki on September 18, 2015 at 0850 hours.