Clinical question: Stroke workup. HIV-positive patient. Signs and symptoms: Slowed speech, right arm weakness, gait instability. Pre- and post enhanced brain MRI:Diffusion weighted images demonstrate a tiny focus of subcortical restricted diffusion (6 mm) in the subcortical white matter of left postcentral gyrus and a larger focus (14.5 x 6.5 mm) in the left paramedian lower pons consistent with acute ischemic strokes without evidence of susceptibility signal changes.Additionally examination demonstrates fairly extensive confluent FLAIR and T2 hyperintensity involving the white matter of bilateral cerebral hemispheres. Lesser degree of similar signal changes are present in bilateral basal ganglia and left pons. Susceptibility signal changes demonstrate multiple tiny foci of microhemorrhages in bilateral subcortical periventricular white matter as well as bilateral basal ganglia and right thalamus. Constellation of above findings are suggestive of advanced chronic minimally hemorrhagic small vessel ischemic strokes. Considering patient's HIV positive status the above detailed findings also could at least partially be secondary to chronic changes of HIV infection. Mild prominence of cortical sulci and supratentorial ventricular system for patient's stated age is suggestive of underlying parenchymal volume loss. Examination also demonstrated evidence of bilateral ovarian degeneration.There is no detectable abnormal enhancement of brain parenchyma or the meninges.Unremarkable images through the orbits and including axial fat sat post enhanced series.Unremarkable calvarium and soft tissues of the scalp. There is evidence of extensive opacification of left maxillary sinus and well-pneumatized paranasal sinuses otherwise.Findings and concerns on this study were discussed by phone (45901) with the emergency room physician (Dr. Padera) at the time of review of the study.
1.There is a 6 mm left postcentral gyrus and a 14.5 x 6.5 mm eft paramedian pons restricted diffusion consistent with acute strokes.2.Extensive periventricular and subcortical as well as bilateral basal ganglia and pontine FLAIR hyperintensity with internal foci of hemorrhage suggestive of chronic minimally hemorrhagic small vessel ischemic strokes. Possibility of overlapping chronic changes of HIV infection cannot be entirely excluded.3.There is no detectable abnormal enhancement on post infused series.4.Prominence of cortical sulci and ventricular system for stated age consistent with underlying parenchymal volume loss.