Clinical question: Rule out expansion of existing ischemia. Signs and symptoms: MCA stroke. Nonenhanced brain MRI:Diffusion weighted series demonstrate multiple new additional small foci of restriction in the left cerebellar and medulla consistent with new acute foci of ischemic strokes. Additionally there are new foci of cortical restricted diffusion extensively in the right frontal lobe and right insular cortex and basal ganglia.The new finding in the right frontal lobe results in thickening of the cerebral cortex and mild effacement of adjacent cortical sulci.Examination also demonstrates interval increased extent of a large left MCA territory subacute ischemic infarct to include left basal ganglion. There is interval significant increase in edema of the left hemisphere in the distribution of left MCA stroke with resultant significant effacement of the cortical sulci and mild rightward deviation of midline of approximately 4 mm. There is extensive susceptibility signal changes throughout the left MCA territory subacute stroke since prior exam and consistent with diffuse petechial hemorrhage. There is mild interval decreased size of ventricular system secondary to increased intracranial pressure. There is crowding of the basal cistern and mild bilateral (L>R) transtentorial inferior herniation of temporal lobes (coronal T2 weighted series 7 images 15 through 19). Postoperative changes of a wide left-sided craniectomy for decompression of a stroke is again identified and significant bulge of the left hemisphere through the craniectomy defect remains grossly similar to prior exam.
1.New additional foci of restricted diffusion in the left cerebellum, medulla, right frontal and right basal ganglion.2.Interval increased extend of subacute left MCA stroke with extensive new petechial hemorrhage and significant increased edema as detailed.3.Mass effect with effacement of basal cistern and (L>R) transtentorial herniation.4.Stable mild rightward deviation of midline and small size of the ventricles. 