Seizures, evaluate for etiology of brain lesions MRI brain:There are multifocal areas of cortical restricted diffusion involving the parietal and occipital lobes, left greater than right. There is an additional punctate focus of restricted diffusion in the right temporal operculum. Increased T2 signal surrounding these lesions is compatible with vasogenic edema. Postcontrast images show mild leptomeningeal and parenchymal enhancement associated with these regions. Punctate foci of hemorrhage are associated with the occipital lobe lesions. There is no significant mass effect, midline shift, or herniation. The ventricles and sulci are normal in size.MRA brain:The anterior intracranial circulation appears patent without flow-limiting stenoses. The posterior intracranial circulation appears patent without flow-limiting stenoses. No evidence of aneurysm.MRV brain:MR venography without gadolinium is of suboptimal quality. The venogram demonstrates grossly patent intracranial venous circulation. The left transverse sinus is not seen on the venogram but demonstrates good enhancement on postcontrast images. There is no evidence of venous sinus thrombosis.
1. Multifocal areas of cortical restricted diffusion primarily in the parietal and occipital lobes, with associated vasogenic edema, minimal hemorrhage, and mild enhancement. Primary differentials include infection/cerebritis as well as multiple infarcts. Given posterior distribution, underlying PRES is a consideration although would be very unusual in this age group. Mitochondrial disease such as MELAS is also a consideration but also not classic. Inflammatory process such as ADEM is also less likely given the pronounced areas of cortical restricted diffusion.2. No significant stenosis involving the major arterial vasculature on MRA. No evidence of venous sinus thrombosis on MRV.