Diagnosis: ComaClinical question: lesions in brainSigns and Symptoms: altered LOC MRI of the brainThe CSF spaces are appropriate for the patient's stated age with no midline shift. There are foci of diffusion restriction present along the right and left parietal lobe which extend to the occipital lobes bilaterally. There are numerous small or punctate foci of diffusion restriction scattered in the cerebellar hemispheres as well as the thalami and splenium of the corpus callosum. There are patchy foci of diffusion restriction along the watershed zones bilaterally between anterior middle cerebral arteries. Compared to the prior exam there is new or diffusion restriction present along the left occipital lobe which was not present on the prior exam and more patchy foci of diffusion restriction left frontal lobe watershed zone and right frontal lobe watershed zone in the more punctate lesions in the cerebellar hemispheres.On susceptibility imaging there are punctate foci of signal loss scattered in the occipital lobes and parietal lobes and the foci of diffusion restriction. Additionally there is gyriform T1 signal hyperintensity bilaterally along the foci of diffusion restriction in the left and right occipital lobes and parietal lobes.There is gyriform and leptomeningeal enhancement present adjacent to areas of infarction in the frontal lobes parietal lobes and occipital lobes and to a lesser degree cerebellar hemispheres.There is a moderate degree of periventricular and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images.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.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.There is no evidence for intracranial aneurysm or cerebrovascular occlusion.The anterior communicating artery is identified. The posterior communicating arteries are not readily identified. The vertebral arteries are similar in size. The right A1 segment is small compared to the left A1 segment. The right posterior communicating artery is medium-sized. The left posterior communicating artery is not readily identified. The MRA images are somewhat degraded by patient motion which may obscure more subtle abnormalities.
1.Large foci of infarction are present in multiple stages in both parietal lobes and both occipital lobes. Additional smaller foci of infarction are scattered in the watershed zones bilaterally and involve frontal lobes and parietal lobes as well as in the cerebellar hemispheres bilaterally with a few punctate foci in the corpus callosum and thalami. Compared to the 8/23/2015 exam there is progression with new areas of infarction especially in the left occipital lobe and scattered in the same regions with continued evolution of infarctions and other territories. There are some small foci of hemorrhage associated with some of these infarctions.2.Periventricular and subcortical white matter changes of a moderate degree are nonspecific. At this age they are most likely vascular related. 3.No evidence for intracranial cerebrovascular occlusion.