Other malaise and fatigue [780.79] / Altered mental status [780.97], Reason for Study: ^Reason: 15yo M with Factor 5 Leiden deficiency and acute facial droop and slurred speech History: slurred speech, facial droop Brain MRIThere are multifocal subarachnoid space high signal intensity lesions on FLAIR images on left superior frontal sulcus, left pre central sulcus, right post central sulcus with relatively large (about 4mm diameter) lesion on the junction of the left superior frontal sulcus and pre-central sulcus. These lesions show susceptibility artifacts on Gradient Echo images indicating possible blood products. There is focal enlargement of subarachnoid space on the left frontal lobe superior frontal sulcus posterior aspect (16.2mm x 10.9mm) indicating possible small arachnoid cyst, no change since prior scan.There is 9.8mm x 18.1mm sized CSF containing lesion, no change in size and configuration since prior scan. The lesion has surrounding parenchymal high signal intensity on FLAIR images, thus this lesion could be related to prior insult related encephalomalacia. There is a small high signal intensity on the left frontal lobe periventricular white matter on FLAIR image which is non specific. The midline structures and cranial-cervical junction are normal. Normal flow voids are identified in the major intracranial vessels. The paranasal sinuses and mastoid air cells are clear.3D MRV brain post-gadolinium with maximum intensity projections of the superficial/deep intracranial venous drainage demonstrate very small right transverse sinus without showing MR evidence of intra-sinus filling defect. The right sigmoid sinus appears to be normal. Superior sagittal sinus, torcular, left transverse sinus, sigmoid sinus and bilateral jugular bulbs appear to be normal.Deep venous drainage system including bilateral internal cerebral veins, vein of Galen and straight sinus appear to be normal.
1. FLAIR high signal intensity lesions on bilateral hemispheres likely represent subarachnoid blood products, possible underlying causes include venous sinus thrombosis with resolving thrombus, cerebral vasculitis, trauma or dural arteriovenous shunting. 2.Hypoplastic right transverse sinus as described above, otherwise unremarkable brain MRV.Comment: considering the patient's history of Factor V Leiden positive, most likely explanation for bihemispheric subarachnoid blood products would be venous thrombosis. Therefore, follow up imaging to verify the resolution of the subarachnoid blood was suggested. And if there is any clinic doubt on the possibility of vasculitis or dural arteriovenous shunting or non-resolution of subarachnoid bloods on follow up, diagnostic catheter angiography needs to be considered. This was discussed with Dr. Marucucilli at the time of this dictation. 