Secondary malignant neoplasm of brain and spinal cord. Cerebral infarction. Altered mental status. Cerebral artery occlusion. MRI of the brainThere is diffusion restriction involving both left and right middle cerebral artery territories with more prominent FLAIR abnormality in the right MCA territory. Most of the MCA territory on each side is involved however, there are some exceptions. The right basal ganglia are involved whereas the left basal ganglia are relatively spared. The right anterior temporal artery territory is involved whereas the left anterior temporal artery territory is relatively spared. There is more involvement of the left orbital gyrus and left middle frontal gyrus than the right orbital gyrus and right middle frontal gyrus.There is 41x31nm axial dimension focus of diffusion restriction with greater FLAIR signal hyperintensity than those in the MCA territories centered in the left fusiform gyrus but involving adjacent brain in the occipital lobe.There are multiple punctate foci of diffusion restriction in the cerebellar hemispheres.No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.The patient is status post posterior fossa craniotomy with a mesh placement for removal of a fourth ventricular mass. There is some FLAIR signal hyperintensity in the medulla adjacent to the tumor bed. There is a fluid collection adjacent to the craniotomy site.Normal vascular flow voids are present in the distal carotid and vertebral arteries, the basilar artery and the proximal anterior and posterior cerebral arteries as well as the internal cerebral veins and superior sagittal sinus. Flow voids of the MCAs are not readily identified.The visualized portions of the paranasal sinuses demonstrate minor opacities. The visualized portions of the mastoid air cells are opacified. The patient is status post intubation. The visualized portions of the orbits are intact.Patient motion degrades the exam.MRA brain:There is occlusion of the right and left MCA at their origins.Antegrade flow is present in the distal internal carotid arteries, the distal vertebral arteries, the basilar artery and the proximal anterior and posterior cerebral arteries.There is no evidence for intracranial aneurysm or cerebrovascular occlusion.The anterior communicating artery is obscured by artifact. The left posterior communicating artery is medium size. The right posterior cerebral artery has fetal origin. The right p1 segment is large. The left vertebral artery is larger than the right vertebral artery. Left PICA is dominant. 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 right carotid bifurcation. Findings raise the question of (but do not confirm) partially occlusive intraluminal thrombus at the left internal carotid artery origin with 70% stenosis by NASCET criteria. There is no significant stenosis along the course of the vertebral arteries.
1.Bilateral MCA territory acute cerebral infarctions (right more extensive than left as detailed above). There are findings suggesting the right MCA territory infarction preceded the left MCA territory infarction.2.Bilateral MCA proximal occlusions. (Given that the left MCA occlusion is more proximal than the territories involved would imply it is suspected that further progression of the left MCA territory infarction may occur.)3.Subacute infarction in the left occipital lobe (posterior circulation)4.Multiple punctate foci of acute or subacute infarction in the cerebellum.5.Findings raise the question of (but do not confirm) partially occlusive intraluminal thrombus at the left internal carotid artery origin with 70% stenosis by NASCET criteria. An ultrasound or CTA may be helpful to help confirm or assess further.6.Status post recent posterior fossa surgery for removal of a mass. Although no residual mass is identified, a contrast enhanced exam would be more sensitive for its detection. Additionally, motion artifact could obscure a subtle residual tumor. There is a fluid collection at the craniotomy site.7.Exam is degraded by patient motion which may obscure more subtle abnormalities.