New ataxia, right sided weakness and dementia, and history of alcohol use. Brain MRI: There is a subcentimeter area of restricted diffusion and high T2 signal in the posterior limb of the left internal capsule. There are also subcentimeter defects without restricted diffusion in the bilateral basal ganglia, thalami, and corona radiata. In addition, there is patchy high T2 hyperintensity in the cerebral white matter. There is a punctate focus of susceptibility effect in the left cerebellar hemisphere, which may represent a chronic microhemorrhage. There is no evidence of acute intracranial hemorrhage. There is diffuse cerebral volume loss. There is no midline shift or herniation. There is no evidence of intracranial mass lesions. The major cerebral flow voids are intact. The skull, paranasal sinuses, and scalp soft tissues are unremarkable.Brain MRA: There is a focal high-grade stenosis of the P1 segment of the left posterior cerebral artery. There is also mild stenosis of the right posterior cerebral artery. The anterior circulation appears to be intact. There is no evidence of saccular aneurysm, within the limits of MRA.Neck MRA: There is mild to moderate stenosis at the left carotid bifurcation, with an apparent focal outpouching in the proximal left internal carotid artery. There is also an apparent focal stenosis of the origin of the right vertebral artery. The left vertebral artery appears to be occluded near the origin and continues distally in the form of a deep cervical artery collateral. There is no evidence of significant steno-occlusive lesions in the right common and internal carotid arteries. There is a focal outpouching along the left lateral aspect of the aorta.
1. Recent infarct in the posterior limb of the left internal capsule with associated early Wallerian degeneration and a focal high-grade stenosis of the left posterior cerebral artery.2. Chronic lacunar infarcts in the bilateral basal ganglia, thalami, and corona radiata, and chronic small vessel ischemic disease in the cerebral white matter.3. Mild to moderate stenosis at the left carotid bifurcation, with an apparent focal outpouching in the proximal left internal carotid artery, which is likely atherosclerotic in nature. A CTA may be useful for further characterization.4. The left vertebral artery appears to be occluded near the origin and continues distally in the form of deep cervical collateral artery. 5. Apparent focal stenosis of the origin of the right vertebral artery.6. A focal outpouching along the left lateral aspect of the aorta may represent an ulcerating plaque or pseudoaneurysm. A CTA may be useful for further characterization.Discussed with MENDELSON, SCOTT at 10:20 AM on 1/7/15.