Clinical question: Sudden onset of right wrist extensor weakness. Signs and symptoms: As above. Nonenhanced brain MRI:Examination demonstrates several tiny foci of restricted diffusion in bilateral cerebral hemispheres. Findings are present in the right occipital lobe, few in right hemispheric periventricular white matter and a tiny focus in the left hemispheric parietal white matter consistent with acute ischemic stroke lesions demonstrate no associated susceptibility signal changes.Additionally there are diffuse confluent FLAIR and T2 hyperintensity of bilateral hemispheric white matter as well as bilateral basal ganglia and minimally in the right thalamus and mild to moderate in the pons all consistent with advanced chronic nonhemorrhagic small vessel ischemic strokes.Incidental note is made of a tiny well-demarcated near CSF signal intensity lesion of the pituitary on the left highly suggestive of a cyst or pituitary adenoma. Finding measures approximately 6 x 4 mm and without detectable mass effect.Mild prominence of supratentorial ventricular system and diffuse uniform prominence of cortical sulci which are believed to be at least partially secondary to underlying parenchymal volume loss secondary to chronic small vessel ischemic strokes.There is no detectable cortical signal abnormality.Signal void of all major intracranial arterial branches are identified and unremarkable.Unremarkable images through the orbits, paranasal sinuses, mastoid air cells and middle ear cavities. Significant leftward deviation of nasal septum and highly suspected leftward projecting bony septal spur is noted.
1.Several scattered hemispheric white matter (R>L) tiny foci of restricted diffusion/acute stroke without hemorrhage as detailed.2.Extensive chronic nonhemorrhagic small vessel ischemic strokes with resultant mild ex vacuo ventriculomegaly and prominence of cortical sulci.3.T2 hyperintense lesion 6 x 4 mm of pituitary likely a cyst or adenoma without mass effect. 