Clinical question: Multiple sclerosis or stroke? History reported of both? Signs and symptoms: Gait disorder and incontinence. Nonenhanced brain MRI:Negative diffusion weighted images for acute ischemic stroke.Examination demonstrates a large focus of encephalomalacia along the medial aspect of right temporal lobe posteriorly and extensively in the right occipital lobe as well as right thalamus which has the appearance of a large chronic right PCA territory ischemic stroke. There is resultant ex vacuo dilatation of occipital horn and the trigone of right lateral ventricle.There are extensive bilateral (R>L) periventricular white matter FLAIR hyperintensity with several demonstrating distinct perpendicular axes to the ventricle which in combination with the patchy foci of FLAIR hyperintensity in the corpus callosum are highly suggestive of demyelinating disease. Possibility of overlapping chronic small vessel ischemic strokes cannot be ruled out and should be considered.Multiple foci of FLAIR hyperintensity are also noted in bilateral (R>L) basal ganglia and left thalamus some with associated susceptibility signal changes. This finding is favored to represent chronic lacunar infarcts. There is evidence of right-sided medullary and degeneration.Constellation of above changes results in significant parenchymal volume loss evident by ex vacuo dilatation of the ventricles and cortical sulci for stated age of 40.Images through posterior fossa also demonstrate multiple foci of FLAIR hyperintensity in bilateral paramedian pons and without detectable lesions in the cerebellar peduncles. This appearance is often represent lacunar ischemic changes. Small focus of FLAIR hyperintensity in the left paramedian cerebellum has a linear appearance and is suggestive of a chronic left PICA territory ischemic stroke.Signal voids of major intracranial arterial branches are identified.Images through the orbits demonstrate chronic hemorrhagic or calcific changes of the left globe with decreased size of globe.Calvarium and soft tissues of the scalp are unremarkable.Sphenoid sinusitis and well-pneumatized other paranasal sinuses.
1.No acute intracranial process and negative diffusion weighted series.2.Large chronic right PCA territory ischemic stroke as detailed.3.Extensive periventricular and subcortical white matter as well as corpus callosum foci of FLAIR hyperintensity some with morphology similar to demyelinating plaques as detailed above. Possibility of overlapping small vessel ischemic strokes should also be considered.4.Multiple foci of FLAIR hyperintensity some with minimal susceptibility signal changes in bilateral basal ganglia and bilateral paramedian pons are more suggestive of chronic lacunar infarcts.5.Significant supratentorial parenchymal volume loss as a result of above findings.6.Tiny linear T2 hyperintensity in the left cerebellum has the appearance of a small chronic ischemic stroke in PICA territory.