Clinical question: stroke or mass work upSigns and Symptoms: right arm weakness MRI of the brainThere are punctate foci of diffusion restriction along the left centrum semiovale, the subcortical white matter of the posterior aspect of the left superior frontal gyrus, the right paramedian corpus callosum, the right cingulate gyrus, the left temporal lobe and the right occipital pole.There is a mild degree of periventricular, brainstem and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images.The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal enhancing mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.Normal vascular flow voids are present in the distal carotid and vertebral arteries, the basilar artery and the proximal anterior, middle and posterior cerebral arteries as well as the internal cerebral veins and superior sagittal sinus.The visualized portions of the paranasal sinuses are clear. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact. The eye lenses are thin.Incidental note is made of a Thornwaldt cyst.MRA brain:Antegrade flow is present in the distal internal carotid arteries, the distal vertebral arteries, the basilar artery and the proximal anterior, middle and posterior cerebral arteries.The middle cerebral artery bifurcations are at the proximal M2 segments.There is no evidence for intracranial aneurysm or cerebrovascular occlusion.The anterior communicating artery is identified and is barely visible. The posterior communicating arteries are medium sized The left vertebral artery is dominant. The left PICA is dominant. The right AICA is dominant.MRA neck:There is opacification of the aortic arch, great vessels from the aortic arch and carotid arteries and vertebral arteries. There is no stenosis identified of the great vessels from the aortic arch. On the basis of NASCET criteria there is no significant stenosis at the carotid bifurcations. There is no significant stenosis along the course of the left vertebral artery. There is high grade stenosis at the origin of the right vertebral artery. The right vertebral artery has a tortuous origin. There is mild narrowing at the origin of the left vertebral artery which is tortuous. The left common carotid artery originates from the innominate artery.
1.A few minor punctate foci of cerebral microinfarcts are present in multiple vascular territories that can be potentially accounted for based only on anterior circulation.2.There is high grade stenosis at the origin of the right vertebral artery. 3.There is no evidence for intracranial cerebrovascular occlusive disease.4.There is no stenosis at the origin of the ICA bilaterally.5.No intracranial aneurysm is appreciated.6.Periventricular and subcortical white matter and brainstem lesions of a mild degree are nonspecific. At this age they are most likely vascular related. 