Diagnosis: alteration of consciousnessClinical question: ischemia, brain mets, seizure focusSigns and Symptoms: seizures MRI of the brainNo diffusion weighted abnormalities are appreciated.There are subtle patchy FLAIR and T2 signal hyperintensities in the occipital lobe subcortical white matter.A punctate focus of signal loss is identified in the left superior frontal gyrus subcortical white matter.The 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.Exam is mildly compromised due to patient motion.MRA brain:Antegrade flow is present in the distal internal carotid arteries, the distal vertebral arteries, the basilar artery and the proximal anterior, middle and posterior cerebral arteries. The LVA is smaller than the RVA.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:The MRA of the neck was compromised due to improper triggering of the imaging relative to the bolus injection. In addition, there is suspicion that some of the contrast extravasated.There is opacification of the aortic arch, the great vessels from the aortic arch and carotid arteries and vertebral arteries. The origins of the great vessels from the aortic arch are not adequately imaged. 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 right vertebral artery. The left vertebral artery appears small but not well imaged. There appears to be antegrade flow in the LVA.
1.There is subtle signal abnormality in the subcortical white matter of the occipital lobes which is non-specific. It is possible that this is related to PRES but the pattern is not classic for it. 2.Left frontal lobe microhemorrhage in isolation is of unknown clinical significance.3.There is no evidence for intracranial or extracranial cerebrovascular occlusive disease.4.There is no evidence for acute ischemic cerebral infarction.5.The left vertebral artery is not adequately imaged. It is therefore possible that it is stenotic .The LVA is the non-dominant vertebral artery in this patient. The neck MRA imaging was compromised due to technical reasons.6.The origins of the great vessels from the aortic arch are not adequately imaged due to technical reasons.7.Exam is mildly compromised due to patient motion. This may obscure more subtle abnormalities.8.9.Contrast extravasation. Please see note above.