Acute midbrain hemorrhage. New vertical gaze palsy.. Many of the images are at least mildly limited by patient motion.MRI: The left midbrain hemorrhage that extends into the posterior medial aspect of the left thalamus has not significantly changed in size since the previous examination. The associated vasogenic edema along T2 hyperintense signal has slightly increased compared to the CT scan, accounting for differences in techniques. There is trace hemorrhage within the occipital horns of the lateral ventricles.There is encephalomalacia in the right basal ganglia and corona radiata, as well as the left corona radiata. In addition, moderate to extensive periventricular confluent T2 hyperintensity, as well as small patches of subcortical T2 hyperintensity are compatible with chronic microvascular ischemia. There is no contrast-enhancing brain lesion. There is no evidence of acute territorial infarct. The pituitary gland appears unremarkable. The ventricles and sulci are enlarged diffusely, reflecting a combination of ex vacuo dilatation from previous infarcts and global cerebral volume loss, but there is no evidence of hydrocephalus otherwise. There is no midline shift or herniation. A left nasal cavity polypoid lesion, a retention cyst in the left maxillary sinus, and secretions in the right posterior ethmoid sinuses are unchanged. The orbits, skull, and scalp soft tissues are grossly unremarkable.MRA: The included upper cervical, petrous, cavernous and supraclinoid internal cleft arteries show preserved flow-related signal and caliber with no flow-limiting lesion or aneurysm. The paired anterior and middle cerebral arteries are also unremarkable. An anterior communicating artery is present. The left vertebral artery is small (both its intracranial and included upper extracranial segments). This is associated with small osseous foramina, which is probably developmental/congenital. The basilar artery is predominantly supplied by the right vertebral artery. The right P1 segment is either absent or very small. The right posterior cerebral artery is supplied through an enlarged right posterior communicating artery (fetal origin; normal variation). The left posterior cerebral artery is conventional in anatomy. Both posterior cerebral arteries are otherwise unremarkable.
1. Left midbrain and thalamic hemorrhage has not significantly changed since the previous CT scan, although the associated vasogenic edema has slightly increased, accounting for differences in technique. Minimal intraventricular extension of the hemorrhage is present as well.2. Extensive chronic small vessel disease and chronic infarcts are unchanged.3. No hemodynamically significant cerebrovascular lesions.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.