 MRI Brain: Mild generalized parenchymal volume loss with prominence of the ventricles and sulci. There are multiple nonspecific foci of T2/FLAIR hyperintensity in the periventricular and subcortical white matter compatible with chronic small vessel ischemic disease. There is evidence of an old watershed ischemia between the right ACA and MCA with small rounded foci of encephalomalacia within gliosis. The cerebellar tonsils are in normal position. There are no masses, mass effect or midline shift. The pituitary gland is normal in size. There is no evidence for intracranial hemorrhage or acute cerebral, brainstem or cerebellar infarction. No diffusion-weighted abnormalities are identified. Trace mucosal thickening of the ethmoid air cells. Status post right partial mastoidectomy. Right lens implant is noted.MRA Brain: Lack of flow is noted involving the distal internal carotid artery. Note is made of a complete circle of Willis with small AComm and PComm arteries present. There is an attempt to supply anterograde flow to the right ACA via the AComm, as well as an attempt to supply antegrade flow to the right MCA via the AComm and right PComm. However, flow related signal appears diminished within the right ACA and MCA compared to the left.The right vertebral artery demonstrates loss of flow with minimal retrograde flow from the basilar artery. There appears to be a right AICA-PICA variant supplying the right PICA territory. No arteriovenous malformations or aneurysms are identified.MRA Neck: The neck portion of the exam is motion degraded. No appreciable flow is visualized in the brachiocephalic artery, although the immediately adjacent right subclavian and common carotid arteries demonstrate normal flow signal, suggesting the the brachiocephalic artery origin lies outside the plane of acquisition. This could be confirmed with CTA or catheter directed angiography. There is severe stenosis of the right common carotid artery at the bifurcation with near complete loss of flow in the right internal carotid artery throughout its entirety. There is a least 50% focal stenosis at the origin of the left internal carotid artery, although convincing measurements are difficult given the motion degradation. The right vertebral artery demonstrates near-complete loss of flow from the origin to its intracranial portion with only minimal retrograde flow from the basilar artery and only minimal attempts at muscular branch reconstitution within the neck. The left vertebral artery is large with a patent origin and appearing normal throughout its entirety. There are no vascular masses identified.
1.No acute ischemic infarction. Chronic small vessel ischemic disease.2.Evidence of chronic watershed ischemia between the right ACA and MCA.3.Near complete loss of flow of the right vertebral artery and the right internal carotid artery with attempts at compensatory flow to both supratentorial and infratentorial structures via a complete circle of Willis and a right AICA-PICA variant.4.At least 50% focal stenosis at the origin of the left internal carotid artery, although convincing measurements are difficult given motion degradation.5.No appreciable flow is visualized in the brachiocephalic artery, although the immediately adjacent right subclavian and common carotid arteries demonstrate normal flow signal, suggesting the the brachiocephalic artery origin lies outside the plane of acquisition. This could be confirmed with CTA or catheter directed angiography. 