altered mental status, atrial fibrillation. There are multiple restricted diffusion lesions on bilateral hemispheres including right parietal lobe, right temporal lobe, right insular, left frontal lobe, left caudate head, left cingulate gyrus, left parietal lobe and left temporal lobe.There are also susceptibility artifacts on the left frontal, right parietal and right temporal lobe indicating hemorrhagic conversion.The ventricles, sulci and cisterns are symmetric and unremarkable. The midline structures and cranial-cervical junction are normal. The paranasal sinuses and mastoid air cells are clear.3D time of flight MOTSA MRA brain images with maximum intensity projections of the anterior/posterior intracranial circulation demonstrate minimal visualization of the left ICA cervical segment to the level of intracranial ICA bifurcation. The left MCA inferior division is reconstituted via left Pcom artery. The right side ICA is patent. Vertebrobasilar system is patent.3D MRA neck post-gadolinium images with maximum intensity projections of the cervical vasculature demonstrate normal flow enhancement in a normal aortic arch origin of the right brachiocephalic, left common carotid, and left subclavian arteries. The left extracranial ICA appears to be significantly narrowed from the level of left CCA bifurcation but still remained forward flow. This finding indicate long standing distal stenosis or occlusion. There is about 50% luminal stenosis on the right vertebral artery origin but that of the left vertebral artery appears to be normal.
1. Multifocal bihemispheric acute ischemic infarctions with evidence of hemorrhagic conversions as described above.2. Significantly narrowed the left ICA from the level of left CCA bifurcation indicating distal stenosis or occlusion.3. The left MCA inferior division is reconstituted mainly through the left Pcom artery but the superior division of the left MCA was not demonstrated. Comment: The Brain MRA WO was not performed with sufficient quality due to motion artifacts as well as low-spatial resolution (352x224) which should be at least 400 x 400 or above or 512 x 512. The neck MRA's FOV was not correct since the area coverage did not include anterior aspect of bilateral ICA thus failed to visualize bilateral cavernous sinus segments of ICAs. Therefore, both MRAs should be repeated without additional charge and under radiologists supervision.