Abulia. Also history of depression, migraines, HTN, seizures on Keppra, pseudotumor status post cisterna-magna shunt with Codman valve last revised in 2009. MRI: Some of the images are degraded by patient motion. There is an area of high T2 signal and restricted diffusion involving a portion of the left globus pallidus and posterior limb of the internal capsule. There is also a punctate focus of encephalomalacia in the right corona radiata. There is a posterior fossa catheter that traverses the left aspect of the fourth ventricle and protrudes into medulla. The fourth ventricle appears similar in size as in 2013, but slightly larger than in 2010. There is persistent effacement of the third ventricle and the lateral ventricles appear slightly larger. There is herniation of a portion of the left medial temporal lobe along with a small portion of the temporal horn into the left perimesencephalic cistern. There also appears to be slumping and distortion of the brainstem with effacement of the surrounding cerebrospinal fluid spaces. The pituitary gland displays convex contours.MRA: The left vertebral artery terminates are the PICA, which is an anatomic variant. There is no evidence of significant steno-occlusive lesions. There is no evidence of cerebral aneurysms.
1. Acute lacunar infarction involving a portion of the left basal ganglia and chronic lacunar infarction involving the right corona radiata.2. The posterior fossa catheter traverses the left aspect of the fourth ventricle and protrudes into medulla. The fourth ventricle appears similar in size as in 2013, but slightly larger than in 2010.3. Cerebellar tonsillar herniation, herniation of a portion of the left medial temporal lobe along with a small portion of the temporal horn into the left perimesencephalic cistern, and slumping and distortion of the brainstem with effacement of the surrounding cerebrospinal fluid spaces may represent sagging brain syndrome. In addition, there is persistent effacement of the third ventricle and the lateral ventricles appear slightly larger. 4. No evidence of significant steno-occlusive lesions in the head and neck arteries.