Diagnosis: Cerebral infarction due to embolism of cerebral arteryClinical question: stroke vs sz, r/o malignancySigns and Symptoms: seizure MRI of the brainNo diffusion weighted abnormalities are appreciated.Foci of encephalomalacia are present in the right middle and inferior frontal gyrus as well as the right basal ganglia. Some periventricular and subcortical white matter lesions are present in the right hemisphere. These correspond to prior foci of infarction depicted on MRI from 6/24/2013.No abnormal enhancing mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.There is a mild degree of periventricular and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images.Normal vascular flow voids are present in the distal carotid and vertebral arteries, the basilar artery and the proximal anterior, middle and posterior cerebral arteries as well as the internal cerebral veins and superior sagittal sinus.The visualized portions of the paranasal sinuses are clear. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact.MRA brain:Antegrade flow is present in the distal internal carotid arteries, the distal vertebral arteries, the basilar artery and the proximal anterior, middle and posterior cerebral arteries. The right vertebral artery appears to be occluded proximally and reconstituted distally via the vertebrobasilar junction. Since the prior exam from 6/24/2013 right distal M1 occlusion has resolved. There is redemonstration of a narrowing of the distal left M1 segment with approximately 70% stenosis as well as a 50% stenosis along the distal ophthalmic segment of the left internal carotid artery. There is 50% stenosis at the cavernous segment of the left internal carotid artery. There is 60% stenosis at the intracranial left vertebral artery distal to the origin of the left posterior inferior cerebellar artery. There is 50% stenosis present at the distal right M1 segment.There is no evidence for intracranial aneurysm or cerebrovascular occlusion.The anterior communicating artery is identified and is medium size. The posterior communicating arteries are intact but small. The left A1 segment is hypoplastic. There is extracranial origin of the left posterior inferior cerebral arteryMRA neck:There is opacification of the aortic arch, great vessels from the aortic arch and carotid arteries and vertebral arteries. There is no stenosis identified of the great vessels from the aortic arch. On the basis of NASCET criteria there is 50% stenosis at the origin of the left internal carotid artery but no stenosis at the origin of the right internal carotid artery. There is no significant stenosis along the course of the left vertebral artery. The right vertebral artery is occluded at its origin.
1.Occlusion of the right vertebral artery with distal reconstitution via the vertebrobasilar junction.2.There is 60% stenosis at the distal left vertebral artery intracranially. 3.There is a 50% stenoses are present along the distal left internal carotid artery at the ophthalmic segment and at the cavernous segment4.50% stenosis at the origin of the left internal carotid artery5.There is 70% stenosis at the left mid M1 segment6.There is 50% stenosis present at the distal right M1 segment7.Encephalomalacia involving the right middle cerebral artery territory related to prior cerebral infarction from 2013.8.There is no evidence for acute cerebral infarction.9.There is no evidence for intracranial neoplasm10.Periventricular and subcortical white matter lesions of a mild degree are nonspecific. At this age they are most likely vascular related. 