Found down, has right gaze preference and left-sided weakness. MRI: There are extensive areas of swelling with T2 hyperintensity and restricted diffusion in the right middle cerebral artery territory, including portions of the posterior temporal lobe, frontal lobe, basal ganglia, and to a lesser extend parietal and occipital lobes. There is a background of cerebral white matter T2 hyperintensity bilaterally, without restricted diffusion. There is also encephalomalacia in the left pons and corona radiata. There is no evidence of intracranial hemorrhage. There is slight narrowing of the right lateral ventricle. There is no midline shift or herniation. The orbits, skull, paranasal sinuses, and scalp soft tissues are grossly unremarkable.MRA: There is paucity of flow-related enhancement in the imaged upper cervical internal carotid artery and throughout the intracranial internal carotid artery, as well as the right middle cerebral artery. Otherwise there is flow-related enhancement of the left internal carotid artery, left middle cerebral artery, and bilateral anterior cerebral arteries. The posterior circulation appears to be intact, aside from mild stenoses of the intradural left vertebral artery.
1. Extensive recent infarction in the right middle cerebral artery territory associated with significant steno-occlusive disease involving the more proximal extracranial internal carotid artery, but no evidence of hemorrhagic transformation or midline shift. Dedicated neurovascular imaging of the neck is recommended.2. Underlying probable chronic small vessel ischemic disease of the bilateral cerebral hemispheres and chronic left pontine and corona radiata lacunar infarcts. 