Reason: Sickle-cell disease without crisis [D57.1] / Moyamoya disease History: surveillance Postoperative changes are again seen from previous bilateral pial synangiosis.There is slight asymmetric right-sided cerebral volume loss, as previously noted, similar to prior exams. There is a similar pattern of T2/FLAIR hyperintensity scattered in the frontal lobe white matter predominantly consistent with chronic small vessel ischemic changes, with additional gadolinium punctate foci. A prominent focus is seen in the posterior aspect of the posterior limb of the right internal capsule on the right side, unchanged.The ventricles and sulci are within normal limits. The basal cisterns remain patent. There is no midline shift or mass effect. There are no new areas of abnormal signal. There is likely a prominent perivascular space along the right basal ganglia. Chronic lacunar infarct is noted in the left caudate, with slightly progressed ex vacuo dilatation of the adjacent left frontal horn. There is no diffusion abnormality. No extra-axial fluid collection is identified.The midline structures and craniocervical junction are within normal limits. Prominent mucous retention cysts are noted in the posterior nasopharyngeal soft tissues.MRA HEAD: Images are somewhat limited by patient motion. There is redemonstration of complete or near complete occlusion of the distal right internal carotid artery, along its supraclinoid portion and terminus. A right M1 segment is again not identified, with numerous serpentine vessels along its expected course consistent with collaterals. Asymmetrically diminished flow related enhancement is identified in the M2 segments and distally. On the left, the carotid terminus and proximal left M1 segment are not well visualized, although there are persistent serpentine vessels along the expected proximal M1 location. The remainder of the left middle cerebral artery appears relatively unremarkable. There is a large right and small left P-comm with relatively large caliber posterior cerebral arteries bilaterally. A1 segments are also not visualized, although diminutive A1 segments are suggested bilaterally. Posterior circulation is relatively unremarkable.There is a similar appearance of thin flow related enhancement traversing the site of right sided synangiosis, at the site of EC-IC bypass. On the left, flow related enhancement associated with the site of EC-IC bypass is not as well visualized as on prior exam, although this in part could be due to artifact.
1. No evidence of acute infarct. Similar pattern of mild to moderate scattered chronic small vessel ischemic changes, most prominent along the frontal lobes bilaterally relating to underlying moyamoya disease, without significant progression.2. Similar appearance of bilateral bilateral distal ICA occlusion/near total occlusion compatible with moyamoya, with resultant collateral vessels including the reconstitution of the left MCA and more distal right MCA.3. Grossly stable appearance of right synangiosis site with decreased delineation of left synangiosis site, which may in part be technical in nature.