Endocarditis, valve unspecified [I38] / Disorientation, unspecified [R41.0] / Septic arterial embolism [I76] / Occlusion and stenosis of unspecified cerebral artery [I66.9], Reason for Study: ^Reason: Eval for progression of septic emboli, characterization of lesions for risk of bleeding on full dose of anticoagulation. Brain MRIThere are multifocal bihemispheric susceptibility lesions indicating petechial hemorrhages including right frontal large subacute hemorrhages with surrounding edema. Especially both right frontal and left cerebellar ICHs show areas of restricted diffusion indicating hemorrhagic conversion of ischemic stroke. Multiple supra and infra tentorial variable sized susceptibility brain parenchymal lesions can be seen in multiple cavernous malformations, however, given then patient's clinical circumstances, these lesions are likely related to septic emboli and/or anticoagulation related petechial parenchymal hemorrhages or chronic hypertension related.Therefore, Gad enhanced MRI is recommended to evaluate any enhancing lesions which may suggest mycotic aneurysm.Loss of normal fatty marrow T1 high signal intensity on clivus and upper cervical vertebral bodies, diagnostic possibilities include systemic disease such as severe anemia or blood dyscrasia related red marrow conversion or metastasis. There is no evidence of acute ischemic lesion on this scan.The ventricles, sulci and cisterns are symmetric and unremarkable.The midline structures and cranial-cervical junction are normal. The paranasal sinuses are clear.Opacification on the left mastoid air cells.Brain MRA3D time of flight MOTSA MRA brain images with maximum intensity projections of the anterior/posterior intracranial circulation demonstrate about 4.5mm sized luminal ectasia at the top of the basilar artery or could be related to a perforator arising from the fetal PCA indicating possible intracranial arterial aneurysm. Comparing to prior CT angiography performed on Mar 27 2016, there was no evidence of ectatic change of the basilar artery. There is no other aneurysm seen on this scan.There is no evidence of arterial luminal stenosis.Bilateral ICAs, MCAs and ACAs appear to be normal.
1. Right frontal and left cerebellar hemisphere ICHs most likely due to ischemic infarction with hemorrhagic conversion.2. Both supra and infra tentorial susceptibility lesions indicate possible petechial hemorrhages. Gad enhanced MRI can be helpful for further evaluation regarding possible multiple mycotic aneurysms.3. About 4.5mm sized aneurysmal lesion on the top of the basilar artery or arising from a perforator of the right fetal PCA.Comment: discussed with cardiac unit fellow and suggested either Gad enhanced MRI to evaluate possibility of multifocal septic emboli related mycotic aneurysm or cerebral angiography to evaluate both intracranial arterial system as well as posterior fossa aneurysmal dilatation.