63 years Male (DOB:5/20/1953)Reason: Evaluate for steno-occlusive disease History: fluctuating L sided weakness, history of R carotid stenosis s/p stentPROVIDER/ATTENDING NAME: IRA J BLUMEN IRA J BLUMEN MRI of the brainNo diffusion weighted abnormalities are appreciated.There is encephalomalacia associated with ex vacuo effect on the right lateral ventricle and T2/FLAIR signal hyperintensity involving the right superior and middle frontal gyri and the adjacent precentral gyrus. Smaller foci of T2/FLAIR signal hyperintensity with widening of adjacent sulci are present in the right parietal lobe adjacent to the interparietal sulcus. T2/FLAIR signal hyperintensity extends to the right centrum semiovale.There is a mild degree of periventricular and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images.No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.Normal vascular flow voids are present in the distal left carotid and vertebral arteries, the basilar artery and the proximal anterior, middle and posterior cerebral arteries as well as the internal cerebral veins and superior sagittal sinus.The visualized portions of the paranasal sinuses mucosal thickening in the left more than the right maxillary sinus as well as opacities elsewhere. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact.MRA brain:Antegrade flow is present in the distal left internal carotid artery, the distal vertebral arteries, the basilar artery and the proximal anterior, middle and posterior cerebral arteries. There is occlusion of the right internal carotid artery. There is circle of willis reconstitution of the right middle and anterior cerebral arteries.There appears to be a high grade stenosis ar the left carotid siphon.The right vertebral artery has a high grade stenosis distally as it pierces the dura.There is no evidence for intracranial aneurysm.The anterior communicating artery is identified and is small. The right posterior communicating artery is relatively small but can be identified. The left posterior communicating artery is tiny. The LVA is larger than the RVA.MRA neck:There is opacification of the aortic arch as well as the innominate artery and left subclavian artery from the aortic arch. The Left common carotid artery does not opacify There is no stenosis identified of the origins of the innominate artery and left subclavian artery from the aortic arch. The right common carotid artery and right internal carotid artery are occluded. On the basis of NASCET criteria there is no significant stenosis at the left carotid bifurcation. There is 33% narrowing of the origin of the left internal carotid artery origin. There is no significant stenosis along the course of the left vertebral artery. The right vertebral artery has a high grade stenosis proximally at its origin and distally as it pierces the dura.
1.Right CCA and ICA occlusion with poor COW collaterals2.Findings suggest a stenosis at the distal left internal carotid artery which may in part be artifactual due to flow phenomenon. A CTA of the brain may help further asses this.3.Right vertebral artery high grade tandem stenoses proximally and distally.4.No evidence for acute ischemic cerebral infarction.5.Encephalomalacia is present in the right hemisphere predominantly involving the right frontal lobe but also patchy areas of the right parietal lobe in a mixed watershed and embolic distribution as detailed above.6.Periventricular and subcortical white matter lesions of a mild degree are nonspecific. At this age they are most likely vascular related. 