Prior history of stroke and interatrial shunt on TTE now with altered mental status status post cystectomy. There are few punctate foci of restricted diffusion in the right occipital lobe and right cerebellar hemisphere suspicious for acute infarct. There are additional multiple scattered small foci of restricted diffusion adjacent to the intraparenchymal hemorrhages described below which are suspected to be artifactual.Innumerable foci of hemorrhage throughout the supratentorial and infratentorial brain. Some lesions demonstrate cystic encephalomalacia compatible with chronic infarcts while others contain some internal T1 or T2 hyperintensity indicating more subacute hemorrhagic infarcts. While most of the lesions have a thin rim of increased T2 signal suggestive of gliosis, no lesions demonstrate clear perilesional T2 edema signal to suggest acute hemorrhage. No evidence of extra-axial hemorrhage.This process is superimposed on a background of mild periventricular and subcortical white matter T2 hyperintensities indicating mild chronic small vessel ischemic changes.The ventricles and basal cisterns are normal in size and configuration.The paranasal sinuses are clear. The visualized mastoid air cells are clear. The orbits are unremarkable.Angiography:Intracranial carotid arteries are widely patent. There is a complete circle of Willis. Left dominant vertebrobasilar system. No significant stenosis in the intracranial anterior or posterior circulation. No intracranial aneurysms.
1. Punctate foci of restricted diffusion in the right occipital lobe and right cerebellar hemisphere are suspicious for small infarcts.2. Innumerable foci of parenchymal hemorrhage throughout the supratentorial and infratentorial brain. These lesions have variable imaging characteristics suggesting a spectrum of both chronic and subacute hemorrhages. While none of the lesions have significant perilesional edema to suggest an acute hemorrhage, noncontrast CT would be useful to confirm absence of acute intraparenchymal hemorrhage. Differential of these multiple hemorrhages is broad but includes thrombotic microangiopathy and coagulopathy. Hemorrhagic metastases while also in the differential is much less likely.