Female, 90 years old, with subarachnoid hemorrhage. Assess for cause. Brain MRI:Trace T1 hyperintensity is seen within the left central sulcus correlating with suspected subarachnoid hemorrhage on prior CT. Sulcal FLAIR hyperintensity is also seen at this location, and within the left superior frontal sulcus and perhaps the right postcentral sulcus. No additional large areas of acute intracranial hemorrhage are suspected.Susceptibility weighted images reveal extensive hemosiderin staining along the surface of the cerebral hemispheres and very conspicuously within many of the cerebral sulci, most notably in the parietal lobes and along the cingulate gyri bilaterally. A focus of parenchymal susceptibility is evident at the gray-white junction in the right paracentral lobule with mild surrounding T2 hyperintensity. These abnormalities are limited to the upper cerebral hemispheres with sparing of the brainstem and posterior fossa structures.Mild leptomeningeal enhancement is seen in the left central and superior frontal sulci, and along the right postcentral sulcus. No enhancing masslike lesions are seen. Extensive patchy and confluent periventricular T2 hyperintensity is noted. In addition, there is a 4 mm focus of mild diffusion restriction in the white matter of the right parietal corona radiata. Diffusion hyperintensity surrounding the right precentral lobule lesion is felt to be artifactual.No large intracranial fluid collections are seen. There appears to be mild encephalomalacia along the right cingulate gyrus. The ventricles and sulci are prominent compatible with mild underlying parenchymal volume loss.Brain MRA:The distal right vertebral artery shows no flow related signal suggesting stenosis or occlusion. The mid to distal basilar artery also narrows at least moderately. No additional significant vascular stenosis or occlusion is seen within the limitations of image quality. The right A1 segment is hypoplastic. No clear evidence of an aneurysm or any vascular malformation is seen.Brain MRV:The superior sagittal sinus, transverse and sigmoid sinuses all demonstrate normal opacification compatible with patency. Likewise, the deep cerebral venous structures opacify normally. No evidence of any anomalous or pathologic venous structure is demonstrated.
1.Trace acute or subacute subarachnoid hemorrhage is seen within the left central sulcus, and perhaps also within the left superior frontal sulcus and the right postcentral sulcus.2.Extensive superficial siderosis is seen involving predominantly the upper aspect of the cerebral hemispheres with sparing of the brainstem and posterior fossa structures. This finding likely represents the sequelae of prior subarachnoid bleeding. However, the etiology for this prior bleeding is not evident on the present examination.3.A focus of parenchymal chronic hemosiderin is seen in the right paracentral lobule. Encephalomalacia is present at the right insula gyrus likely reflecting chronic ischemia. Also noted is a small, acute small vessel stroke in the right parietal white matter.4.Within the limitations of image quality, no aneurysm or vascular malformation is detected on MRA images. The right distal vertebral artery shows no flow related signal which may indicate stenosis or occlusion. In addition, the mid to distal basilar artery appears to be at least moderately narrowed.5.MRV imaging of the intracranial venous structures is within normal limits.