Clinical question: Stroke. Signs and symptoms: Right-sided weakness. Nonenhanced CT of brain:Subacute nonhemorrhagic right cerebellar and right medullary region in the distribution of right pica stroke is again identified. There is only subtle mass effect with effacement of sulci and no evidence of mass effect on the fourth ventricle.Well demarcated nonhemorrhagic lacunar infarct of right thalamus as was noted on prior MRI exam.Small vessel disease of indeterminate age is subcortical white matter of bilateral cerebral hemispheres (left greater than right). Overall this appearance also is similar to prior MRI examination. No evidence of hemorrhage.CTA of the cervical region:Right carotid, circumferential plaque at the origin of right internal carotid artery with no hemodynamically significant stenosis is noted. The right common carotid artery including its origin and the rest of the cervical portion of right internal carotid artery is unremarkable.Left carotid, circumferential complex plaque at the origin of left internal right artery with no minimal calcification is noted. This results in significant high-grade stenosis of left internal carotid artery at this site. The left common carotid artery and including its origin and the rest of the cervical portion of the left internal carotid artery is unremarkable and widely patent.Right vertebral artery is small in caliber and is believed to represent a non-dominant vertebral (and normal anatomical variation). There is no evidence of a stenotic lesion.Left vertebral artery, there is a non-calcific circumferential plaque at the origin of the dominant the left vertebral artery is noted. There appears to be more than 50% stenosis at this site. The rest of left vertebral artery is unremarkable.Limited view of lower tic origin the origin of major vessels are essentially unremarkable.CTA of intracranial circulation:Carotid system, patent bilateral supraclinoid internal carotid arteries. Minimal atherosclerotic irregularities noted.Middle cerebral arteries and their branches demonstrate mild atherosclerotic disease however but no evidence of any large vessel vascular occlusion or high-grade stenosis.Bilateral anterior cerebral arteries demonstrate multiple foci of high-grade stenosis and ectatic changes. Findings are secondary to atherosclerotic disease. Vertebral basilar system, diffuse atherosclerotic disease of the basilar artery with multi-level areas of mild vascular lumen compromise. Similar findings are noted in the intracranial component of dominant left vertebral artery in particular in its distal component.The right vertebral artery is the nondominant vessel. There is discontinuity of the distal component of the right vertebral artery. This represents occlusion of this vessel proximal to its junction with the basilar artery. The very distal portion of right vertebral artery is visualized and shows significant decrease in its caliber to its patent more proximal component.
1.Revisualization of multiple small vessel strokes, lacunar strokes and a right cerebellar -- medullary stroke in the distribution of right pica branch. No evidence of hemorrhagic transformation.2.Atherosclerotic plaque with minimal calcification however no hemodynamically significant stenosis at the origin of right internal carotid origin.3.Significant atherosclerotic disease of the left internal carotid artery origin with very high-grade stenoses.4.More than 50% stenosis at the origin of the dominant left vertebral artery and otherwise unremarkable vertebral arteries bilaterally in the neck.5.Atherosclerotic disease of supraclinoid internal carotid arteries, bilateral middle cerebral arteries with areas of mild to moderate vascular compromise. Atherosclerotic disease results in high-grade stenosis and ectatic changes of bilateral anterior cerebral arteries.6.Patent dominant left vertebral artery intracranially with minimal atherosclerotic disease.7.Patent basilar artery however but extensive atherosclerotic disease and mild vascular lumen compromise.8.Complete occlusion of the mid section of the intracranial component of the nondominant right vertebral artery. There is significant decrease in the caliber of visualized very distal right vertebral artery compared to patent a proximal component. If further evaluation is required for management a conventional angiogram would improve detection and the cause of occlusion and morphology of this vessel evaluation.