Reason: r/o stroke History: aphasia MRI of the brainarea of diffusion traction is present which involves the posterior aspect of the insular cortex, adjacent left superior temporal gyrus, adjacent left some central lobular and adjacent left supramarginal gyrus. There are additional punctate foci of diffusion restriction in the left postcentral gyrus and inferior parietal lobule.There is signal loss on susceptibility weighted imaging within the left medullary draining veins.On susceptibility imaging there are foci of signal loss present in the basal ganglia and in the right frontal subcortical white matter indicative of prior microhemorrhages. The there are T2 signal hyperintensities in the basal ganglia at these foci of basal ganglia microhemorrhage.There is a mild degree of periventricular and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images.The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal enhancing 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.There are subdural effusions present in the posterior fossa and supratentorial brain probably related to atrophy.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.MRA brain:Antegrade flow is present in the distal right internal carotid artery, the distal right vertebral artery, the basilar artery and the proximal anterior, middle and posterior cerebral arteries. The left internal card artery is occluded and reconstituted via the left posterior communicating artery.There is occlusion of the left middle cerebral artery at the distal M1 segment involving a divisional branch each which includes the left posterior parietal artery. There is antegrade flow in the some of the superior division branches as well as some of the inferior division branches. It is suspected this represents a partial occlusion of inferior division trunk with complete occlusion of the posterior parietal artery.There is no evidence for intracranial aneurysm or cerebrovascular occlusion.The anterior communicating artery is identified and is medium size. The posterior communicating arteries are medium sized. The vertebral arteries are asymmetric with the right larger than left. Extracranially the left vertebral artery appears to be occluded.MRA neck:There is opacification of the aortic arch, great vessels from the aortic arch and carotid arteries and vertebral arteries. The left common artery originates from the innominate artery.There is high-grade stenosis present at the proximal right vertebral arteryThere is 60% stenosis present along the proximal left subclavian artery.Complete occlusion of the origin of the left internal carotid artery.Complete occlusion at the origin of the left vertebral arteryOn the basis of NASCET criteria there is no significant stenosis at the right carotid bifurcation.
1.Occlusion of the left internal card artery at its origin without distal reconstitution of the communicating segment via the left posterior communicating artery.2.Occlusion at the inferior division of the left middle cerebral artery with complete occlusion of branches centered around the left posterior parietal artery.3.Occlusion of the left vertebral artery proximally with distal reconstitution via the vertebrobasilar junction.4.Acute infarction in in the left middle cerebral artery territory centered around the left posterior parietal artery territory.5.There is high-grade stenosis present at the proximal right vertebral artery6.There is 60% stenosis present along the proximal left subclavian artery.7.The findings are suggestive of hypoxia to the left hemisphere.8.Old lacunar infarcts in the basal ganglia are likely associated with prior hemorrhage.