Aphasia and left-sided weakness. Stenosis potentially requiring intervention. Brain MRI: Many of the sequences are degraded by patient motion. There are small areas of restricted diffusion and high T2 signal in the right superior and middle frontal gyri. There is underlying encephalomalacia in the right basal ganglia, middle frontal gyrus, and right corona radiata. There is also diffuse patchy cerebral white matter T2 hyperintensity without corresponding restricted diffusion. There is no evidence of intracranial hemorrhage or mass. The ventricles are unchanged in size and configuration. There is no midline shift or herniation. The major cerebral flow voids are intact. The orbits, skull, paranasal sinuses, and scalp soft tissues are grossly unremarkable.Brain MRA: The images are largely degraded by patient motion. There is paucity of flow-related enhancement in the right internal carotid vein. There is tenuous reconstitution of flow-related enhancement in the right middle cerebral artery at the circle of Willis, with a relative paucity of flow-related enhancement in the distal middle cerebral artery branches. There also appears to be asymmetrically less flow-related enhancement in the right anterior cerebral artery. There also appears to be irregular narrowing of the bilateral posterior cerebral arteries. The intradural vertebral arteries and Neck MRA: There is no discernible enhancement of the entire right internal carotid artery. The right common carotid and external carotid arteries appear to be patent. The left internal carotid, common carotid, and external carotid arteries also appear to be patent. However, there appears to be stenosis of the bilateral vertebral artery origins.
1. Acute right middle cerebral artery territory infarct superimposed upon chronic small vessel ischemic disease and chronic infarcts, without gross hemorrhagic transformation.2. Critical steno-occlusive disease at the origin of the right internal carotid artery. Further evaluation via Doppler ultrasound may be useful.3. Apparent stenosis of the bilateral vertebral artery origins. Discussed with Physician: AGNIESZKA A ARDELT at 2:40 PM on 10/28/15.