Clinical question: Evaluate CVA's, ischemia. Signs and symptoms : Status post CVA. Nonenhanced brain MRI:The examination demonstrates many small foci of hyperintensity on diffusion weighted images in the anterior right paramedian medulla, right middle cerebellar peduncle, left mid and posterior temporal white matter, right cerebral peduncle, midline splenium of corpus callosum, splenium of corpus callosum and several larger lesions in bilateral subcortical and periventricular white matter of the cerebral hemispheres. Only the tiny right anterior medullary lesion demonstrate true restricted diffusion and consistent with an acute lacunar infarct. None of the other foci of diffusion hyperintensity demonstrate restricted diffusion and are not consistent with acute strokes. These lesions however are all well visualized on flair and T2-weighted images as well demarcated foci of hyperintensity and majority demonstrate tiny internal signal void suggestive of vasculature. Findings are highly suspected of demyelinating disease. Follow-up with enhanced imaging is recommended for better assessment and to exclude other pathologies.Examination additionally demonstrated multiple ill-defined foci of flair hyperintensity in bilateral middle cerebral peduncles, diffusely in the pons and a focus of hemorrhagic encephalomalacia in the right cerebellum. Many of these lesions are highly suggestive of chronic ischemic changes however possibility of overlapping chronic demyelinating disease cannot be entirely excluded.Slight prominence of cortical sulci and supratentorial ventricular system for patient's stated age is noted. No evidence of midline shift.The sequelae of bilateral internal carotid arteries , bilateral anterior and middle cerebral arteries are identified. Small caliber bilateral vertebrals and basilar artery is noted. There is abnormal signal intensity of the left intracranial vertebral artery (increased T2 signal within the lumen) which could be artifactual or as a result of vascular lumen compromise. Follow-up with vascular imaging is recommended considering punctate focus of restricted diffusion in the medulla.Unremarkable barium and orbits. Left maxillary sinusitis and unremarkable other paranasal sinuses
1.Diffusion-weighted images demonstrate a single tiny focus of restricted diffusion in the right anterior paramedian medulla (acute stroke).2.None of the many additional supratentorial and infratentorial foci of diffusion hyperintensity (including two lesion in the corpus callosum) demonstrate no restricted diffusion and are not consistent with acute stroke. These findings are concerning for demyelinating disease and follow up with enhanced imaging is recommended for further assessment and exclusion of other pathology.3.Additionally patchy foci of flair hyperintensity is noted in the periventricular and sub-cortical white matter, pons, bilateral middle cerebellar peduncles, corpus callosum and right cerebellum as detailed above. Please see above comments