Right face weakness and slurred speech. Brain MRI: There is a 25 mm wide area of predominantly gyriform high T2 signal and restricted diffusion involving the left posterior cingulate gyrus and adjacent parietal lobe superimposed upon a background of otherwise unchanged diffuse cerebral and pontine white matter T2 hyperintensity without restricted diffusion. There is also a punctate focus of restricted diffusion and high T2 signal in the left thalamus. There is no evidence of intracranial hemorrhage. The ventricles and basal cisterns are unchanged in size and configuration. There is no midline shift or herniation. The right vertebral artery flow void is deficient. The orbits, skull, and scalp soft tissues are grossly unremarkable. There is minimal mucosal thickening in the right maxillary sinus.Brain MRA: There is paucity of flow-related enhancement of the C3 and C4 segments of the right vertebral artery. There is reconstitution of flow-related enhancement at the proximal basilar artery via the left vertebral artery. The proximal portions of the anterior cerebral circulation appear to be intact. There is no evidence of saccular aneurysms.Neck MRA: There is lack of opacification of the majority of the right vertebral artery beyond a short V1 segment. There is enhancement of the distal portion of the V2, as well as the V3 and V4 segments of the right vertebral artery. There is no evidence of significant steno-occlusive lesions in the other major cervical arteries. There is a three vessel arch.
1. Small area of acute infarction involving the left posterior cingulate gyrus and adjacent parietal lobe and punctate acute infarct in the left thalamus superimposed upon a background of chronic white matter small vessel ischemic disease, but no evidence of hemorrhagic transformation.2. Significant steno-occlusive disease involving the proximal right vertebral artery with distant hemodynamic impact.Discussed with Dr. Burns at 11:10 AM on 1/24/15.