Clinical question: CVA. Signs and symptoms: Left weakness. CT of brain without infusion: Findings consistent with small vessel disease of indeterminate age are again identified. The strokes are again bilateral subcortical, periventricular and basal ganglia. No definitive evidence of cortical stroke is detected. There is no evidence of hemorrhage. This findings remains similar to what was noted on prior examination of the same date. Cortical sulci, ventricular system and all CSF cisterns remain within normal. Hard or follow-up with an MRI examination is recommended.CTA of intracranial circulation:Right internal carotid:There is heavy calcification of cavernous carotid however on sagittal MIP images no stenosis is detected. The supraclinoid right internal carotid artery is unremarkable. A normal and patent right posterior communicating artery is identified. The right anterior and middle cerebral arteries are visualized and patent. Very minimal irregularity of the vessel walls on 3-D reformatted images may indicate atherosclerotic disease. There is however no evidence of any area of significant stenosis.There is filling of both anterior cerebral arteries from the right side which is secondary to hypoplastic left A1. Right ophthalmic artery on 2-D reformatted images is identified.Left internal carotid:Heavy vascular calcification of the left cavernous carotid on sagittal MIP images are noted. No hemodynamically significant stenosis is detected. Supraclinoid internal carotid artery demonstrate minimal vascular calcification and is otherwise unremarkable. Eight patent prominent left posterior communicating artery is identified. Ophthalmic artery on coronal MIP images is identified.There is hypoplastic left A1 and with no visualization of the A1 segment.The left middle cerebral artery and all of its branches are well visualized and with no evidence of definitive pathology. Very minimal irregularity on 3-D images of these branches may represent atherosclerotic disease however possibility of reformatted artifact cannot be entirely.Vertebral -- basilar system:A very small right vertebral artery note the process well please and within the subarachnoid space at the level of foramen magnum. On 2-D reformatted images a small right pica is identified. Distal portion of small right vertebral artery appears to continue and communicates with the basilar artery.A dominant left vertebral artery is noted to traverse the foramina magnum and give rise to a patent left pica branch. Basilar artery is uniformly narrow along its entire course and is smaller than is expected. I believe this is secondary to prominent patent bilateral posterior communicating arteries that supply the posterior cerebral arteries. Very minimal irregularity of the lumen of basilar artery on 3-D reformatted images may represent minimal atherosclerotic disease. No significant foci of stenosis however is identified.Superior cerebellar arteries are visualized and unremarkable.Hypoplastic bilateral P1 segments of posterior cerebral arteries are noted.MRA of neck:Right carotid.Right brachial cephalic artery and including its origin remains normal. The origin of right common carotid artery and its entire course remains patent. Heavy vascular calcification at the level of carotid bifurcation with extension into proximal internal carotid artery is present. There is however no hemodynamically significant stenosis. The cervical portion of right internal carotid artery is unremarkable.The external carotid arteries unremarkable.Left carotid.Small calcification at the origin of the left common carotid artery is noted. No stenosis at this location is identified. Shallow plaques within the mid cervical portion of the left common carotid artery some with minimal calcification are present. There is minimal compromise of the lumen however no hemodynamically significant stenosis. Minimally calcified plaques at the origin of the left internal carotid artery are noted. No hemodynamically significant stenosis of the left internal carotid artery at any level is detected. External carotid artery is unremarkable.Vertebral -- basilar system:Left vertebral.Dominant left vertebral artery is patent throughout its course. The overall caliber of this dominant vessel is however smaller than usual which is believed to be secondary to patent large bilateral posterior communicating arteries. A small calcific plaque at the origin of left vertebral artery is noted. No focal area of the stenosis of the left vertebral.Right vertebral.The intracranial component of very small size right vertebral artery is identified on 2-D reformatted images and can be traced retrogradely to the level of foramina magnum. This artery cannot be identified from the level from the magnum inferiorly to approximately C2 level. This is small vertebral artery is reidentified at C2 level and can be traced retrogradely to C3 -- C4 intervertebral disk level. There is no visualization of vertebral artery from this level inferiorly to the level of the origin of right vertebral artery. The right subclavian is tortuous and demonstrates minimal after sclerotic disease with calcification however no significant stenosis is detected.
1.Minimal small vessel disease and a known definitive at pressure or interval change since prior study of the same date.2.No evidence of any hemodynamically significant stenosis of the intracranial vasculature. Minimal atherosclerotic disease is suspected.3.Heavy vascular calcification of bilateral cavernous carotids with no detectable significant stenosis.4.Uniformly smaller than expected basilar artery lumen which is believed to be secondary to a large patent bilateral posterior communicating arteries. No significant focal area of stenosis.5.No significant stenosis of carotid arteries in the neck. Please see above comments.6.Vascular calcification of carotid bifurcations.7.Complete occlusion of the right vertebral artery at its origin up up to approximately C3 -- C4 level. Fragmented visualization of small right vertebral artery superiorly to the level of foramina magnum. Patent right vertebral artery intracranially and with visualization of right pica.8.Patent small dominant left vertebral artery as detailed.9.Visualized origins of major vessels arising from the arch appear unremarkable.