 Brain MRI:There is a small focal area of restricted diffusion with ADC hypointensity within the midbrain, just rightward posterior-lateral to the cerebral aqueduct. There is a questionable punctate focus of restricted diffusion along the rightward superior aspect of the vermis.T2 hyperintensity is present within the white matter, pons, and medial cerebellar hemispheres, confluent in several locations, without restricted diffusion. Punctate foci of susceptibility hypointensity are noted in the right cerebellum, midline midbrain, leftward pons, and medial bilateral cerebellar hemispheres. A small focus of encephalomalacia is noted within the peripheral left cerebellar hemisphere.The ventricles and sulci are normal in size. The cerebellar tonsils are in normal position. There are no masses, mass effect or midline shift. The pituitary gland is normal in size. There are no extraaxial fluid collections or subdural hematomas. The paranasal sinuses and mastoid air cells are clear. Brain MRA:There is smooth stenosis of a left M2 MCA segment. There is also smooth tapering of the distal right vertebral artery with a more focal significant stenosis at the confluence with the left vertebral artery. Antegrade flow is maintained through these segments.There is antegrade flow within the distal left vertebral artery, within the basilar artery, distal bilateral internal carotid arteries and carotid siphons and bilateral anterior and posterior cerebral arteries as well as right middle renal artery. No arterial occlusions, arteriovenous malformations, or aneurysms are identified.
1.There is a small focal area of restricted diffusion with ADC hypointensity within the midbrain, just rightward posterior-lateral to the cerebral aqueduct consistent with acute to subacute ischemia. There is a questionable punctate focus of restricted diffusion along the rightward superior aspect of the vermis.2.Advanced chronic small vessel ischemic disease involving both supratentorial and supratentorial brain. Aforementioned foci of susceptibility most likely represent remote microhemorrhage associated with the small vessel disease.3.There is smooth stenosis of a left M2 MCA segment. There is also smooth tapering of the distal right vertebral artery with a more focal significant stenosis at the confluence with the left vertebral artery. Antegrade flow is maintained through these segments.