71-year-old female with past medical history significant for HLD, HTN, DM, and 2 prior ischemic strokes, and mixed Alzheimer's and vascular dementia who presented to the ED with right sided weakness that started suddenly on 8/30/15. Brain MRI:There is a new focal diffusion restriction along the posterior limb of the left internal capsule (the territory of the anterior choroidal artery). Along the posterior aspect of this diffusion restriction, there is a tiny focus of susceptibility effect that may represent a small associated petechial hemorrhage. Also, there is a tiny focus of new diffusion restriction and T2 hyperintensity along the posterior surface of the right cerebellar hemisphere just medial to focal volume loss related to a previous infarct. The chronic left occipital parenchymal injury (encephalomalacia) has not changed since the previous examination. Similar abnormality involving the left precentral gyrus is also unchanged. These are most compatible with chronic infarcts. A tiny remote infarct causing focal volume loss involves the superficial/posterior part of the medial right cerebellar hemisphere, just lateral to the above described acute/subacute infarct. The frontoparietal scattered and confluent T2 hyperintense foci remain also not significantly changed. These are compatible with chronic microvascular ischemia/infarcts. There is no space-occupying brain lesion. There is no midline shift. The dilatation of the ventricles and the other CSF-containing spaces reflecting volume loss is unchanged. There is no intracranial hemorrhage.There is minimal ethmoidal and sphenoidal mucosal thickening. Otherwise, the paranasal sinuses and the mastoid air cells are clear. The orbits are normal. There is a 2.6 cm homogeneously T2 hyperintense, well-circumscribed, lobulated left parapharyngeal mass which is probably arising from the deep lobe of the left parotid gland. This mass has not significantly changed since January 2015 or the more remote neck soft tissue CT scan from August 9, 2013 and favored to represent a pleomorphic adenoma.Cranial MRA:The intracranial segments of internal carotid arteries show preserved caliber and flow-related signal with only slight asymmetry (the left being smaller which is probably explained by the hypoplastic left A1 described below). The left A1 segment is small (hypoplastic) but there is a large anterior communicating artery and right A1. The anterior and middle cerebral arteries are preserved in caliber and flow-related signal. There is slight narrowing and irregularity involving the distal right vertebral artery. The left posterior cerebral artery is small which may be related to decreased demand associated with the left occipital infarct. The right posterior cerebral artery and its branches are normal.Neck MRA:The aortic arch branching pattern is conventional. The cervical common and internal carotid arteries are tortuous but show no significant loss of caliber or flow/contrast-related signal. The vertebral arteries are also preserved without significant stenosis in the neck.
1.Acute infarct involving the posterior limb of the left internal capsule involving the anterior choroidal artery territory. There is punctate focus of susceptibility effect involving the posterior aspect of the infarct which is new since prior and suspected to represent petechial hemorrhage. No frank intraparenchymal hematoma.2.Subtle focus of restricted diffusion involving the right posterior aspect of the right cerebellar hemisphere with T2 hyperintensity also suspected to represent a recent infarct. There is an adjacent area of gliosis likely related to remote ischemia. 3.Left occipital and precentral gyrus infarcts are chronic. Also, there is a moderate burden of white matter microvascular ischemia/infarcts.4.There is no significant stenoocclusive head or neck arterial disease. There is minimal narrowing involving the distal right vertebral artery.5. Probable pleomorphic adenoma involving the deep lobe of the parotid appears unchanged.Dr. Monther Qandeel has discussed the above findings with Dr. Bara Fintel on the day of the examination at 1500 hours.