Diagnosis: Essential (primary) hypertensionClinical question: assess vasculatureSigns and Symptoms: left facial droop, patellar hyperreflexia, subtle left sided weakness MRI of the brainA focus of diffusion restriction is present in the right centrum semiovale and internal capsule.There is a moderate degree of periventricular and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images.Punctate foci of T2/FLAIR signal hyperintensity are present in the left thalamus and adjacent internal capsule as well as the left side of the pons.The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.Normal vascular flow voids are present in the distal 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 are clear. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact.Exam is degraded by patient motion. There is wrap around artifact obscuring the left cerebellar tonsil and medial left cerebellar hemisphere on T2 axial imaging.MRA brain:There is artifact obscuring visualization of the left vertebral artery and the left PICA. Exam is degraded by patient motion.Antegrade flow is present in the distal internal carotid arteries, the distal vertebral arteries, the basilar artery and the proximal anterior, middle and posterior cerebral arteries.There is no evidence for intracranial aneurysm or cerebrovascular occlusion.The anterior communicating artery is identified and is large. The right A1 segment is larger than the left A1 segment.There is fetal origin of the right PCA. The right p1 segment is small. There is asymmetry in size of the vertebral arteries with left larger than right vertebral artery.
1.Acute lacunar infarct is present in the right centrum semiovale.2.Lesions the left thalamus and brainstem are suspected to be related to chronic stage lacunar infarcts.3.Visualization of the left vertebral artery and the left PICA is partly obscure by artifact. Findings as they stand suggest the presence of a 5mm aneurysm at the PICA origin. A CTA would be helpful to further evaluate. Alternatively, a repeated MRA when the patient is able to better tolerate it would be helpful.4.Periventricular and subcortical white matter changes of a moderate degree are nonspecific. They could be vascular related, related to demyelination, trauma, vasculitis, sarcoid. They are nonspecific. 5.Exam is degraded by patient motion and other artifacts which may obscure more subtle abnormalities.