Clinical question: Evaluate for infarct. Signs and symptoms: Left gaze deviation, right face arm and leg weakness, hyperreflexia. Nonenhanced brain MRI:Diffusion weighted images demonstrate a large patchy foci of restricted diffusion extensively involving the left corona radiata, partially involving the left basal ganglia and left insular cortex and left anterior temporal cortex. This finding is not associated with any hemorrhagic changes. This finding is also well visualized on flair and T2 weighted images and consistent with an acute nonhemorrhagic ischemic stroke. Additionally examination demonstrates numerous patchy confluent flair hyperintensity in bilateral subcortical and periventricular white matter consistent with chronic small vessel ischemic strokes without evidence of hemorrhagic changes.Slight prominence of cortical sulci and ventricular system remains within normal for patient stated age of 84. Although not a dedicated vascular imaging there is apparent small caliber and abnormal signal intensity of the left M1 segment of middle cerebral artery. Follow-up with vascular imaging is recommended.Images through the orbits, paranasal sinuses and mastoid air cells are unremarkable. Calvarium and soft tissues of the scalp are also unremarkable.
1.Large patchy acute nonhemorrhagic ischemic stroke in the left corona radiata, left basal ganglia/left insular cortex and left anterior temporal cortex as detailed. No appreciable mass effect.2.Extensive chronic nonhemorrhagic small vessel ischemic stroke in the supratentorial brain parenchyma.3.Abnormal caliber and signal intensity of the M1 segment of the left middle cerebral artery suspicious for high-grade stenosis or possible thrombus. Recommend follow up with dedicated vascular imaging.