 Brain MRI: A region of restricted diffusion is noted in the left MCA distribution within the left angular gyrus, left dorsal insular cortex and left superior temporal gyrus and measures 5.0 x 5.1 cm. The region demonstrates susceptibility abnormalities indicating petechial hemorrhages. Mild mass effect is noted but no midline shift or herniation. Additional mild scattered periventricular and subcortical white matter hypointensities likely represent chronic small vessel ischemic disease.The ventricles and sulci are normal in size. The cerebellar tonsils are in normal position. The pituitary gland is normal in size. There are no extraaxial fluid collections or subdural hematomas. Small right maxillary mucous retention cyst. The paranasal sinuses and mastoid air cells are clear. Brain MRA:The M1 segment of the left MCA is patent. However, within the M2 segment of the left MCA and beyond is moderate to severe stenosis of multiple branches which most likely includes branches leading to the infarcted region. An acute occlusion of these vessels is highly suspected. There is also mild atherosclerotic involvement of the right middle cerebral and bilateral anterior cerebral arteries but no significant flow-limiting stenosis. The intracranial portions of the internal carotid arteries are patent without significant steno-occlusive disease. The focal loss of signal in the petrous internal carotid arteries is artifactual. There is antegrade flow within the vertebrobasilar system. There is a normal variant hypoplastic P1 segment of the right PCA. No steno-occlusive disease, dissection or aneurysm.
1.Acute MCA distribution infarct involving the left parieto-temporal region with a component of petechial hemorrhage. There is mild mass effect but no midline shift or herniation.2.Moderate to severe stenosis of many M2 segment branches of the left MCA which most likely includes branches leading to the infarcted region. An acute occlusion of these vessels is highly suspected. 3.Mild chronic small vessel ischemic changes as well as mild atherosclerotic disease elsewhere intracranially as described above.