Diagnosis: Transient cerebral ischemic attack, unspecifiedClinical question: 87M with concern for TIA vs ischemic eventSigns and Symptoms: word finding difficulty MRI of the brainNo diffusion weighted abnormalities are appreciated.There are small T2 hyperintense and T1 and FLAIR hypointense lesions in the right basal ganglia.There is 5-10 periventricular and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images.The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal enhancing mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.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 demonstrate a mucous retention cyst in the left maxillary sinus The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact. The eyeball lenses are thin.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. There is a high-grade stenosis present along the distal right M1 segment of the middle cerebral artery with approximately 70% stenosis proximal to the bifurcation. This was also present on the 3/30/2012 exam and has not progressed significantly.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. The vertebral arteries are similar in size. There is extracranial origin of the right posterior inferior cerebellar artery. The left posterior communicating artery is medium-sized. The right posterior communicating artery is small. The anterior communicating artery appears to be fenestrated. The left internal carotid artery is larger than the right internal carotid artery. The left A1 segment is larger than the right A1 segment.MRA 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 no significant stenosis at the carotid bifurcations. There is no significant stenosis along the course of the vertebral arteries. The left common carotid artery originates from the innominate artery.
1.There is a high-grade stenosis present at the distal right M1 segment of the right middle cerebral artery proximal to the bifurcation. This was also present on the 3/30/2012 exam and has not progressed significantly.2.A couple small lesions in the right basal ganglia may be attributable to old right-sided lacunar infarcts. There is no evidence for acute ischemic cerebral infarction.3.Periventricular and subcortical white matter changes of a mild degree are nonspecific. At this age they are most likely vascular related. Their number is relatively small and likely this is of little clinical consequence.