Male, 78 years old, with altered mental status, history of AML in blast crisis, evaluate for ischemia versus hemorrhage versus leukostasis. MRI brain:Restricted diffusion compatible with acute ischemia is seen within the right MCA distribution affecting the posterior frontal lobe, much of the parietal lobe, part of the insula, and part of the temporal and occipital lobes.Restricted diffusion is also seen within the left MCA territory involving a moderately sized portion of the left posterior frontal lobe and frontal operculum. Numerous small foci of restricted diffusion are evident elsewhere in both cerebral hemispheres and in the cerebellum. The affected tissue demonstrates T2 hyperintensity and mild edema but no significant generalized mass effect, midline shift or brain herniation is seen. No hemorrhagic conversion is suspected as of yet. There are small foci of susceptibility scattered through the brain but these may represent chronic microhemorrhages.Extensive patchy periventricular T2 hyperintensity is seen, a nonspecific finding which may reflect chronic microvascular ischemic disease. There is mild effacement of the right lateral ventricle. Elsewhere, the ventricular system is unremarkable.MRA brain:Abrupt cessation of flow related signal is seen within one of the proximal M2 branches of the right MCA. A paucity of MCA vessels is visualized in the right cerebral hemisphere. Scattered areas of narrowing are seen within the M2 and M3 branches of the left MCA as well. The intradural right vertebral artery is not well visualized.MRA neck:The origins of the great vessels are not well visualized due to technical limitations. The common carotid and internal carotid arteries are free of significant vascular stenosis. The left vertebral artery is free of significant vascular stenosis. The right vertebral artery is not visualized.
1. A large acute infarct is evident within the right MCA distribution with a moderately sized acute infarct seen in the left MCA distribution. Scattered small ischemic lesions are demonstrated elsewhere throughout the cerebrum and cerebellum. The pattern of disease is largely territorial and therefore a thromboembolic process or possibly in situ cerebral vessel thrombosis would be the favored etiology.2. Correlating with the large right MCA infarct, there is abrupt occlusion of one of the proximal M2 branches of the right MCA. Scattered vascular stenoses are also seen within the left MCA distribution.3. The right vertebral artery is not identified in the neck or intradurally. This may reflect a proximal occlusion or severe atherosclerosis or a congenitally diminutive vessel. The cervical carotid vessels are unremarkable.