Diagnosis: Dizziness and giddinessClinical question: evaluate for CVASigns and Symptoms: evaluate for CVA MRI of the brainThe CSF spaces are appropriate for the patient's stated age of 70 with no midline shift. The right lateral ventricle is larger than the left.No foci of diffusion restriction are identified in the brain parenchyma. A couple small foci of susceptibility effect in the left middle frontal gyrus correspond to calcifications identified on a recent head CT. These were not present on the prior exam from 2012. These ae associated with surrounding signal hypointensity on T2/FLAIR and a minor degree of subtle encephalomalacia (volume loss).A punctate focus of susceptibility effect is present in the left hippocampus and left middle temporal gyrus in addition to the left middle frontal gyrus foci corresponding to calcifications.There is a moderate degree of periventricular and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images. These appear stable since 2012 but more prominent (possibly due to differences in MR technique).A small focus of encephalomalacia has developed in the right middle temporal gyrus.There is redemonstration of a couple irregularly shaped T2 hyperintense foci in the brainstem and another couple in the basal ganglia as well as T2 and FLAIR hyperintense lesions in the internal capsules.No abnormal mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.Normal vascular flow voids are present in the distal carotid and vertebral arteries, the basilar artery and the proximal anterior, middle and posterior cerebral arteries as well as the internal cerebral veins and superior sagittal sinus.The visualized portions of the paranasal sinuses are clear. The visualized portions of the mastoid air cells are clear. A mucous retention cyst is present in the left maxillary sinus. The visualized portions of the orbits are intact. The eye lenses are thin. There is thinning of the posteromedial sclera with AP elongation of the eyes bilaterally and symmetrically.A 4mm well circumscribed T2/FLAIR hyperintense lesion in the right parotid gland is stable.A 4mm well circumscribed T2 hyperintense lesion in the right paramedian pharyngeal mucosal space thought to represent Thornwaldt cyst is stable.Incidental note is made of partial empty sella.MRA brain:Antegrade flow is present in the distal internal carotid arteries, the distal vertebral arteries, the basilar artery and the proximal anterior, middle and posterior cerebral arteries.There is no evidence for intracranial aneurysm or cerebrovascular occlusion.The anterior communicating artery is identified and is small. The posterior communicating arteries are intact and very small. The right vertebral artery is very small.MRA neck:There is opacification of the aortic arch, great vessels from the aortic arch and carotid arteries and vertebral arteries. The great vessels from the aortic arch and the origins of the vertebral arteries are not adequately evaluated. There is a CTA of the chest from 4/2013 which does not identify any significant stenosis of the great vessels not the origin of the left vertebral artery. On the basis of NASCET criteria there is no significant stenosis at the carotid bifurcations. There is no significant stenosis along the course of the vertebral arteries. The right vertebral artery is small.
1.No evidence for acute ischemic cerebral infarction.2.Periventricular and subcortical white matter changes of a moderate degree are nonspecific. At this age they are most likely vascular related. They have not changed since the prior exam.3.Calcific density lesions along the left middle frontal gyrus were not present on the prior exam of 2012. These are non-specific. They could represent dystrophic calcifications associated with prior microhemorrhages. Other causes may include dystrophic calcifications from inflammatory lesions or calcific emboli.4.A new (since 2012) small (1cm) focus of encephalomalacia is present in the right middle temporal gyrus along its posterior aspect.5.There is no change in the lesions of the brainstem, internal capsules and basal ganglia suspected to represent old lacunar infarcts.6.No evidence for intracranial aneurysm.7.No evidence for intracranial or extracranial cervicocerebral vascular occlusive disease.8.The great vessels from the aortic arch and the origins of the vertebral arteries are not adequately evaluated. 9.A 4mm benign appearing lesion in the right parotid gland is stable.10.Staphylomas of the eyes are not substantially changed.