Per chart, this is a 68 year-old African-American F with DM (on insulin), HTN, morbid obesity, depression, OA of knee and shoulder who presents with acute onset dizziness and imbalance since early AM on 6/18 that lasted for hours. Right upper extremity ataxia on neurologic exam. Assess for brainstem infarct, acute vertigo and cerebellar signs. There are two small foci of diffusion restriction in the left thalamus. The ventricles and sulci are prominent, consistent with mild age-related volume loss. The basal cisterns remain patent. There is no midline shift or mass effect. There are scattered punctate foci and confluent areas of abnormal T2/FLAIR hyperintensity within the periventricular and subcortical white matter and pons, consistent with mild to moderate chronic small vessel ischemic changes. No extra-axial fluid collection is identified. There is opacification of a left posterior ethmoid air cell. Normal flow-voids are demonstrated in the major intracranial vascular structures. The midline structures and craniocervical junction are within normal limits.
1. Two small foci of acute infarcts in the left thalamus. No evidence of acute intracranial hemorrhage or mass effect.2. Mild to moderate chronic small vessel ischemic changes. Urgent findings discussed with Dr. Buerki on 6/18/2015 at 3:15pm.