Clinical question: 70-year-old female is status post aortic valve replacement, here with recurrent syncopal episodes. Signs and symptoms: Hypoglycemia versus seizure. Pre and post enhanced brain MRI:No evidence of restricted diffusion.Examination demonstrates scattered periventricular and subcortical foci of FLAIR hyperintensity in bilateral cerebral hemispheres and minimally within the pons and bilateral cerebellar hemispheres. Findings are highly suggestive of chronic small vessel ischemic strokes of moderate degree. There is suggestion of mild interval progression of disease since prior exam from 2014.Slight prominence of cortical sulci and ventricular system demonstrate no significant change since prior exam.The signal void of major intracranial arterial branches are identified.There is no detectable abnormal enhancement of brain parenchyma, leptomeninges, calvarium, scalp or the orbits.The signal intensity of intracranial venous sinuses are within normal and normal pattern of enhancement.
1.No acute intracranial process.2.Moderate chronic small vessel ischemic strokes in the bilateral subcortical and periventricular white matter as well as pons with slight interval progression since 2014 exam.3.Bilateral small (R>L) chronic cerebellar ischemic strokes.4.No detectable abnormal enhancement.