Right-sided weakness and aphasia. BRAIN MRI:Correlating with the hypoattenuation on the previous CT scan along the left precentral sulcus, there is diffusion restriction reflecting the recent/acute nature of the infarct. The infarct correlates with relatively well-circumscribed prominent T2-hyperintensity and minimal mass-effect that involves the respective parts of the middle and inferior frontal gyri. Multiple additional foci of diffusion restriction are present in the left frontal white-matter as well. There is no associated susceptibility effect to indicate hemorrhagic transformation.There are multiple near-CSF-intensity foci in the frontal and parietal white-matter that are associated with surrounding T2 FLAIR hyperintensity, compatible with chronic lacunar infarcts. Hyperintense T2/FLAIR signal extending along the posterior limbs of the internal capsules and cerebral peduncles may represent Wallerian degeneration and is more pronounced on the right.There is diffuse prominence of the ventricles and other CSF-containing spaces reflecting generalized brain volume loss. There is no midline shift or brain herniation.There are small retention cysts in the maxillary sinuses. There is minimal fluid in the right mastoid air cells posteriorly. These findings are nonspecific. There is no gross orbital abnormality or destructive skull lesion.CRANIAL MR ANGIOGRAPHY:There is generalized irregular/segmental attenuation of the intracranial arteries, which reflects diffuse atherosclerosis. The cavernous segments of the internal carotid arteries are mildly affected, right more than left, which correlates with calcification on the CT scan but there is no high-grade internal carotid artery stenosis. The most severe anterior circulation stenosis involves the proximal left A1 and the proximal left A2 segments. An anterior communicating artery is present. The middle cerebral arteries also show significant atherosclerotic involvement which results in marked attenuation of the flow-related signal in the distal right M2 segment at the trifurcation. The more peripheral middle cerebral artery branches show multifocal stenosis as well. Attenuation of flow-related signal in the anterior left middle cerebral artery branches correlates with the region of the above described acute left frontal infarct.The right vertebral artery terminates in the right posterior inferior cerebellar artery. The basilar artery is a continuation of the left vertebral artery. Left posterior cerebral artery shows fetal origin while the right one shows a fetal-type origin, which are normal variations. Diffuse atherosclerotic involvement of the posterior cerebral arteries is present as well.CERVICAL MR ANGIOGRAPHY:Mild attenuation of the proximal segment of the right common carotid artery is probably artifactual. The remainder of the common and cervical internal carotid arteries show relatively preserved contrast opacification without significant stenosis. There is poor visualization of the origin of the right vertebral artery, which is suspected to represent high-grade stenosis. The more distal right vertebral artery is patent. Right vertebral artery is nondominant. There is also mild multifocal irregularity involving the cervical vertebral artery segments.
1.Acute infarcts involving the left frontal lobe in the distribution of the left middle cerebral artery. No evidence of hemorrhagic transformation or significant intracranial mass effect.2.Changes of chronic microvascular ischemia and multiple chronic lacunar infarcts are present bilaterally in the frontoparietal lobes. Generalized brain volume loss is moderate.3.There is moderate multifocal irregularity involving the intracranial circulation related to atherosclerotic disease. There is relatively worse focal stenoses at the left A1, left A2, and distal right M1 segments. No large vessel occlusion. Asymmetric attenuation of flow-related signal in the anterior left middle cerebral artery branches correlates with a recent infarct. 4.Cervical MR angiography demonstrates no significant stenosis involving the common carotid or internal carotid arteries in the neck. There is mild multifocal irregularity of the vertebral arteries as well as suspected high-grade stenosis at the right vertebral artery ostium. Cervical vertebral artery segments are otherwise patent. 