Diagnosis: Multiple sclerosisClinical question: history of MS now with acute neurologic symptomsSigns and Symptoms: history of MS now with new neurologic symptoms MRI of the brainA punctate focus of signal hyperintensity is present in the right frontal periventricular white matter. It does not correspond to a focus of diffusion restriction on the ADC maps. It represents T2 shine through.The CSF spaces are appropriate for the patient's stated age with no midline shift. There is a small subdural effusion redemonstrated in the posterior fossa which is stable and could simply relate to some atrophy.There is redemonstration of a moderate degree of periventricular and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images. Additional T2 and FLAIR signal hyperintense lesions are present in the brainstem and cerebellar hemispheres. There is no substantial change since last years exam.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 eyeball lenses are thin.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.There is no evidence for intracranial aneurysm or cerebrovascular occlusion.The anterior communicating artery is identified and is medium size. The posterior communicating arteries are intact. The left posterior communicating artery is medium-sized. The right posterior communicating artery is tiny. The anterior communicating artery is medium-sized. The left vertebral artery is very small relative to the right vertebral artery.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 vertebral arteries. The left common carotid artery originates from the innominate artery. There is narrowing of the left subclavian artery by approximately 65% proximal to the origin of the left vertebral artery. The left vertebral artery origin is tortuous. The left vertebral artery is smaller than the right vertebral artery.
1.There are multiple periventricular and subcortical white matter lesions as well as brainstem and cerebellar lesions present which are stable when compared to the prior exam and compatible with patient's clinical history of multiple sclerosis.2.65% stenosis at the left subclavian artery proximal to the left vertebral artery origin. Please note the left vertebral artery is much smaller than the right vertebral artery. This has not changed substantially since last years exam.3.There is no evidence for intracranial cerebrovascular occlusive disease appreciated.