Altered mental status.Additional clinical history from electronic medical records: 44-year-old woman with ESRD on dialysis; missed her Wednesday and Friday dialysis. Admitted because of change in the LOC. The behavioral change can be due to encephalitis/meningoencephalitis/ seizures/ metabolic disturbance/ stroke (PRES, or ischemic stroke) MRI: There are multiple oval-shaped focal T2-hyperintense, T1-hypointense lesion in the cerebral white-matter that are somewhat perpendicularly oriented relative to the long axis of the lateral ventricles. There is multifocal punctate susceptibility effect in the cerebrum and cerebellum without associated edema, may reflect hemosiderin staining. These microbleeds are probably related to end-stage renal disease-associated microangiopathy. Otherwise, there is no acute intracranial hemorrhage or acute infarct. There is no mass-effect, midline shift or brain herniation. The ventricles, sulci and basal cisterns are mildly to moderately enlarged, reflecting underlying global brain volume loss. The major intracranial vascular flow voids are preserved.There are retention cysts in the maxillary sinuses. There has been bilateral eye lens placement. There is no gross destructive skull lesion or gross scalp soft tissue abnormality.MRV:The study is markedly limited, in part by patient motion and in part by lack of intravenous contrast. The superior sagittal and straight sinuses as well as the deep cerebral veins are grossly patent with preservation of their flow voids on T2/FLAIR conventional sequences.MRA:Slight irregularity of caliber involving the distal cervical internal carotid arteries likely represent artifact. Otherwise, there is no flow-limiting stenosis, occlusion or aneurysm of the major intracranial arteries.
1.Multifocal cerebral white-matter lesions are nonspecific with differentials including demyelinating disease, or prior ischemia or inflammation.2.There is no acute infarct. No findings to suggest encephalitis within the limits of noncontrast study. Multiple scattered foci of chronic microhemorrhage are nonspecific but may represent microangiopathy related to chronic renal disease.3.MRA shows no significant steno-occlusive disease.4.MRV is very limited by lack of contrast and by patient motion though there is no definite sign of occlusive thrombosis of the major dural sinuses. However, if there is high suspicion for venous thrombosis, consider contrast-enhanced CT venogram.