85 year old patient with left pontine infarct in bilateral cerebellar lesions please evaluate patient has right hemiparesis and gaze deviation to the rightTechnique: Contiguous axial images of the brain. Subsequently high resolution contiguous axial images were obtained through the lower half of the head and neck and aortic arch during bolus injection of intravenous contrast. On the noncontrast head CT a hypodense focus corresponding to the MRI abnormality along the left cerebellar hemisphere measuring 25 x 15 mm axial dimensions is present and not clearly evident on the prior exam. Hypodense foci in the lower mid brain and upper pons predominant involving the left upper pons and lower midbrain were also not readily identified on the prior exam. There are punctate lesions present along the right posterior inferior cerebellar artery territory and to a lesser degree left posterior inferior cerebellar artery territory.There is opacification of both distal vertebral arteries along their cervical segments. The right vertebral artery is somewhat smaller than the left intracranially and along the cervical segment. The right posterior inferior cerebellar artery does display contrast enhancement as does the left, however, the right vertebral artery does not opacify distal to the posterior inferior cerebellar artery suggesting that it is likely either highly stenotic or occluded. The basilar artery, therefore fills from the left vertebral artery. There are some mural calcifications associated with luminal narrowing as the left vertebral artery enters the subarachnoid space. The left anterior inferior cerebellar artery is larger than its right counterpart. The basilar artery is highly attenuated distal to the AICA origins and suspected to be occluded below the level of the superior cerebellar arteries. The posterior communicating arteries are of similar in size to the P2 segments. The P1 segments are asymmetric right larger than left. The right P1 segment is about the same size as the posterior communicating artery on the right side the left one is smaller than the left P2 segment. It is and therefore considered that the superior cerebellar arteries fill from the anterior circulation as do the posterior cerebral arteries in this patient.There are atherosclerotic calcifications along the distal internal carotid arteries bilaterally. No significant stenosis is appreciated along the anterior or posterior cerebral arteries. The anterior communicating artery is identified and is relatively small compared to the A1 segments which are approximately equal in size. There are atherosclerotic calcifications present along the carotid bifurcations however on the basis of NASCETcriteria no significant stenosis is present along the carotid bifurcations. There is some mild narrowing of the left internal card artery just distal to its origin but approximately a 40%.The left vertebral artery is significantly narrowed at its origin with approximately an 80% stenosis along its cervical segment there are foci of narrowing along the mid cervical vertebral artery with approximately 60% stenosis at the C4-5 disk space level. View right vertebral artery is small and intracranially essentially only supplies the right posterior inferior cerebellar artery which is otherwise disconnected. There is some mild prominent muscular branch is present along the the tube in segment collateralization to the left occipital artery is unknown basis of this exam.The patient is intubated both endotracheally and nasogastric.Some atherosclerotic calcifications are present along the aorta and some of the branches. There is atherosclerotic in narrowing of the innominate artery by approximately 75%. There are degenerative changes present along the cervical spine at C6-7 with left sided neural foraminal narrowing, and c3-4 with right sided neural foraminal narrowing.
1.Subacute foci of infarction in the left cerebellar hemisphere more than the right as well is within the upper pons and lower midbrain left worse than right. No evidence for hemorrhagic conversion2.Occlusion or near occlusion of the right vertebral artery distal to the origin of the posterior inferior cerebellar artery.3.High-grade stenosis at the origin of the left vertebral artery with a tandem lesion along the mid cervical segment of the left vertebral artery and atherosclerotic in narrowing of the left internal artery as it enters the subarachnoid space. 4.There is occlusion or near occlusion of the basilar artery between the anterior inferior cerebellar artery and the superior cerebellar artery origins.5.The posterior communicating arteries are fairly large as described above. The anterior circulation appears to be the dominant supply for the posterior cerebral arteries as well is the superior cerebellar arteries. 6.High-grade stenosis (approximately 75%) of the innominate artery due to atherosclerotic narrowing7.Mild narrowing at the left internal carotid artery origin as described above. no significant stenosis at the carotid bifurcations on the basiss of NASCET criteria.8.If clinically appropriate, a more detailed assessment of the supply to the posterior circulation may be provided via conventional angiography to confirm or exclude complete occlusion of right vertebral artery and basilar artery and to provide a more accurate description of the percent of stenoses described above, assess circulation time and to identify any collateralization from the external circulation to the intracranial circulation - which cannot be identified on this exam.9.Degenerative changes are present in the cervical spine as indicacated above. Please correlate with clinical symptoms.