 MRI BRAIN:There is an approximately 1.0 x 1.1 cm round area of ill-defined enhancement in the right insular cortex with surrounding vasogenic edema. There is gradient susceptibility in this area suggestive of hemorrhage, similar to prior examination.There is a moderate degree of periventricular and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images. There are no new foci of diffusion restriction to suggest acute or subacute ischemia. Small area of FLAIR signal abnormality measuring approximately 1.0 x 1.4 cm demonstrated in the left parahippocampal gyrus, increased in size from prior examination when it measured 0.7 cm. There is no significant diffusion hyperintensity remaining, and ADC images are unremarkable. There are postsurgical changes consistent with right-sided craniotomy of uncertain etiology despite review of EMR. There is T2 and FLAIR signal hyperintensity present along the anterior aspect of the right inferior frontal gyrus with associated volume loss. Punctate foci of signal loss on susceptibility weighted imaging is present in the left inferior parietal lobule and another in the left superior frontal gyrus. Additional small foci of susceptibility artifact are demonstrated in the bilateral cerebellar hemispheres. The visualized portions of the paranasal sinuses demonstrate partial opacification of the left maxillary sinus. Left maxillary mucosal retention cyst again seen.MRA Head:There is diffuse dolichoectasia of the intracranial vasculature. The intracranial internal carotid arteries are normal in course. The middle cerebral arteries and anterior cerebral arteries are unremarkable. A right middle cerebral artery branch does course in the location of the right subinsular abnormality although it appears unremarkable. The vertebral arteries and posterior cerebral arteries are normal in course. There is no evidence of flow-limiting stenosis or aneurysm.MRI Neck:There is an approximately 5.6 x 4.0 x 3.5 cm ovoid enhancing mass in the right submandibular region, previously 2.5 x 2.4 cm. This mass demonstrates diffusion restriction. The mass is located along the lateral aspect of the submandibular gland and is inseparable from the submandibular gland itself. No significant lymphadenopathy is appreciated within the neck. No additional masses are identified.There is a medialized left vocal cord with thickening of the aryepiglottic fold with a small area of fat just cranially, which may relate to chronic atrophy from paralysis.A small cyst is incidentally noted involving the facial soft tissues overlying the left maxilla (series 18, image 6). There is multilevel spondylosis of the cervical spine with reversal of the cervical lordosis at C3-C4 level. There is moderate spinal stenosis at the C3-C4 level. Multilevel loss of intervertebral disc spaces is demonstrated.
1. Rounded 1.1 cm hemorrhagic focus with associated ill-defined enhancement in the right insula is again seen with surrounding FLAIR hyperintensity and is suspicious for hemorrhagic metastatic disease versus hemorrhage of other etiology, potentially amyloid angiopathy. 2. Small hemorrhagic foci are again seen in the right and left cerebellar hemisphere as well as smaller hemorrhagic lesions in the left frontal lobe and left parietal lobe. These are nonspecific and could relate to chronic hemosiderin deposition or mineralization, potentially from amyloid angiopathy.3. Small focal area of signal abnormality in the left parahippocampal gyrus has slightly increased in prominence but remains nonspecific. Previous diffusion hyperintensity is no longer conspicuous, and findings could represent an evolving area of ischemia. 4. Findings suggest encephalomalacia along the right prefrontal artery territory. This could be a result of prior vascular event or possibly related to the previous unknown surgery. 5. There is an approximate 5.6 cm lobular enhancing mass in the right submandibular region with diffusion restriction, increased in size from prior CT dated 6/11/2016, consistent with known neoplasm. Adjacent lobulated enhancement may represent additional components of the mass versus adjacent lymphadenopathy.6. There is redemonstration of a medialized left vocal cord with thickening aryepiglottic fold, which may relate to chronic paralysis.7. MRA of the head demonstrates no aneurysm or flow-limiting stenosis. Diffuse dolichoectasia of the intracranial vessels.