Diagnosis: Disturbance of skin sensationClinical question: please r/o stenosis or occlusive vessels and look for signs of strokeSigns and Symptoms: left facial weakness and slurred speech MRI of the brainScattered foci of diffusion restriction are present in the right post central gyrus and the right inferior parietal lobule. A couple punctate foci of diffusion restriction are present in the medial right parietal lobe and the centrum semiovale.A T2 and FLAIR signal hyperintense area is present in the right centrum semiovale associated with mild ex-vacuo effect on the adjacent lateral ventricle.There is a mild degree of periventricular and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images.There is signal loss in the right hemispheric cortical venous vasculature presentThe CSF spaces are appropriate for the patient's stated age with no midline shift. 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.A small focus of encephalomalacia is present in the right cerebellar hemisphere.MRA brain:Antegrade flow is present in the distal internal carotid arteries, the distal left vertebral artery, the basilar artery and the proximal anterior, middle and posterior cerebral arteries.There is a high grade stenosis at the distal right ICA involving the ophthalmic segment and the communicating segment.There is occlusion of the right vertebral artery present. There is a stenosis at the intracranial left vertebral artery at the PICA origin.There is fetal origin of the left PCA with a small left p1 segment. The right PCOMA is small.The ACOMA is medium size. There is triplication of the ACA. The right A1 segment is very small.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 vertebral arteries are similar in size.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 LVA has aortic arch origin. The RVA is very small and occluded distally.
1.High grade distal right ICA long segment stenosis with small right PCOMA and hypoplastic right A1 segment.2.Occlusion of the right vertebral artery with small left p1 segment and high grade stenosis at the intracranial LVA at the PICA origin.3.Acute foci of infarction in the right MCA territory.4.Chronic right sided watershed distribution infarctions and ischemic changes to the right MCA territory.5.Findings suggest hypoxia to the right MCA territory.6.Periventricular and subcortical white matter changes of a mild degree are nonspecific. At this age they are most likely vascular related. 7.Small right cerebellar chronic stage infarction.