Diagnosis: Altered mental status, unspecifiedClinical question: determine age of right MCA infarctSigns and Symptoms: AMSComments: Verifying presence of metal with family | There is encephalomalacia involving much of the right hemisphere and predominantly the right middle cerebral artery territory. This is associated with multiple punctate foci of susceptibility effect on susceptibility weighted imaging within the right middle cerebral artery territory. Some susceptibility effect is present in the region of the basal ganglia. There is a small area of diffusion restriction involving the right basal ganglia and portions of the right centrum semiovale. Within this area of diffusion restriction there is T2 hypointensity and even some FLAIR hypointensity as well as some T1 hyperintensity.A focus of encephalomalacia is present along the medial aspect of the left occipital lobe extending into the medial left temporal lobe and the left posterior cerebral artery territory.Some small T2 hyperintense lesions are present in the cerebellar hemispheres.There is a moderate degree of periventricular and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images.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 right cerebral peduncle is small and has abnormal signal. Additionally there is some abnormal signal in the right pons and medulla. This is suggestive of Wallerian degeneration.The visualized portions of the paranasal sinuses demonstrate scattered opacities. The visualized portions of the mastoid air cells are partially opacified on the right side more than the left.. The visualized portions of the orbits are intact.Exam is somewhat compromised due to patient motion.
1.There is encephalomalacia involving a significant portion of the right hemisphere predominantly involving the right middle cerebral artery territory but also involving portions of the anterior cerebral artery territory and posterior cerebral artery territory. Most likely is related prior cerebral infarction in the right middle cerebral artery territory.2.There is encephalomalacia present in the left medial temporal and occipital lobes. Most likely this is related to prior cerebral infarction in the left posterior cerebral artery territory.3.Diffusion restriction is present in the region of the right basal ganglia and centrum semiovale which suggests some superimposed subacute infarction, however, the pattern is somewhat unusual and could represent sequela from a prior hemorrhagic event superimposed on prior infarction given it a more complex appearance.4.Periventricular and subcortical white matter changes of a moderate degree are nonspecific. At this age they are most likely vascular related. 