Severe headaches and new left-sided weakness and paresthesia. History of moyamoya disease and synangioplasty. BRAIN MRI:Multifocal chronic infarcts involving the frontal lobes and the right temporal and occipital lobes are not significantly changed since the previous examination including the associated FLAIR hyperintensity related to gliosis. The previously seen punctate and confluent cerebral white-matter T2 FLAIR hyperintensities that may reflect chronic microvascular ischemia is also not significant changed. Small cerebral white-matter and left thalamic chronic lacunar infarcts are unchanged. The cerebellum and brainstem remain preserved. There is no acute infarct or intracranial hemorrhage. There is prominent mineralization involving the basal ganglia which was present previously. There is no mass effect, midline shift or brain herniation. No hydrocephalus or extra-axial collections. Following contrast injection, there is prominent enhancement involving small lenticulostriate arteries related to moyamoya pattern.Multiple small defects involving the parietal bones are related to previous revascularization (synangiosis) procedures. There is nonspecific trace mucosal thickening in the maxillary and ethmoid sinuses. There is no gross orbital abnormality.CRANIAL MRA:The included upper cervical internal carotid arteries as well as the petrous and cavernous internal carotid arteries are very small and stable to minimally worse in the interval, with subtle differences which may related to technique. The internal carotid flow-related signal disappears towards the distal part of the ophthalmic segments bilaterally. There is also no detectable flow in the M1 and M2 segments. There is also no flow in the proximal anterior cerebral arteries. Flow in the distal anterior cerebral arteries remains attenuated on the right. In addition, there is a 3 mm saccular aneurysm arising from the terminal part of the right internal carotid artery. The aneurysm appears new since the previous examination.Patent vessels traverse the above described parietal skull defects representing the anastomoses between the superficial temporal arteries and the intracranial circulation. However, there is no detectable flow-related signal in the right sylvian branches of the middle cerebral artery and there is only faint signal in the left sylvian branches. This has not changed since the previous examination. The vertebral basilar system is notable for unchanged significant attenuation of the proximal P1 segments with small tortuous collateral vessels.
1.Previously seen multifocal chronic infarcts remain unchanged since the February 2010 examination. No evidence of acute infarct or new infarcts since the prior study.2.While the known moyamoya stenoses and occlusions are not significantly changed since the 2010 examination, there is a new 3 mm aneurysm arising from the right carotid terminus. Other findings compatible with moyamoya involvement are described above.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.