67-year-old female with worsening right-sided weakness and adenocarcinoma of the lung with brain metastases. MRI BRAIN:The wedge-shaped left parietal lobe MCA territory restricted diffusion has expanded since the prior exam, now extending into the left temporal lobe and to a smaller extent the left insula. No new separate areas of restricted diffusion are seen to indicate other areas of ischemia. Within the left parietal MCA territory, there is a pattern of intrinsic, gyriform T1 hyperintensity with minimal, if any, superimposed enhancement. This pattern likely represents laminar necrosis. There is some visualization of the previous gyriform pattern of susceptibility artifact on 11/4/2015, however imaging at 1.5 T likely results in decreased conspiuity of this finding when compared to prior. There has been interval increase in surrounding FLAIR abnormality, consistent with increasing edema. This results in effacement of the adjacent sulci and of the posterior horn of the left lateral ventricle. No midline shift and the basal cisterns appear intact. The enhancing, known metastases appear stable to slightly improved given changes in technique. There are no new foci of metastatic disease seen.Several foci of T2/FLAIR hyperintensity are seen in the bilateral subcortical and periventricular white matter, which are nonspecific, but compatible with chronic small vessel ischemic changes. There are no new areas of hemorrhage nor large extraaxial collections. Sella and orbits are grossly within normal limits. Paranasal sinuses and mastoid cells are clear. Bone marrow signal and extracranial soft tissues are within normal limits.MRA NECK:Common origin of the brachiocephalic artery and the left carotid artery without evidence for stenosis of the great vessels. Small caliber of the right vertebral artery is likely secondary to atherosclerotic disease, though suboptimal image quality limits examination.There are no stenoses of the bilateral common, internal or external carotid arteries or of the bilateral carotid bifurcations. There is no evidence for vasculitis, fibromuscular dysplasia or dissection of the carotid or vertebral arterial systems within the neck. There are no vascular masses identified. MRA BRAIN:There is narrowing of a long segment of the inferior division of the left MCA that appears worsened allowing for differences in technique. In fact, the there is loss of flow signal completely at the distally aspect of this branch which is new from prior examination. Maderate narrowing in the left A2 ACA and in the left P3 PCA branches are unchanged.
1. Slowly progressive ischemic injury in the posterior left MCA territory is worsened and correlates with MRA findings of worsening inferior branch left MCA long segment stenosis and distal occlusion.2. The left vertebral artery is small in caliber. Otherwise, MRA of the neck is unremarkable.3. No new hemorrhage or metastatic disease is visualized. The previously seen metastatic disease is stable to improved from prior exam.