Reason: ACUTE STROKE PROTOCOL perfusion post-stroke History: stroke, cerebral infarction identified on CT. Patient status post right sided aneurysm embolization. Please evaluate for thrombus currently at the distal right internal carotid artery and perfusion asymmetry between the two hemispheres which may place the patient at risk for additional cerebral infarctions. MRI of the brainThere are foci of diffusion restriction in the right MCA territory and right PCA territory. One in the right inferior frontal gyrus measures 25mm, one in the right occipital lobe measures 30x20 mm, one in the right inferior parietal lobule measures 25x36mm. Smaller (<10mm) ones are present in the right caudate nucleus and right insular cortex.Perfusion images demonstrate mild delay in mean transit time with increased cerebral blood volume in the right versus the left hemisphere. There is no significant difference in the cerebral blood flow between the two hemispheres with the exception of the infarcted areas.There is a 6mm thick hyperdense subdural collection adjacent to the right hemisphere associated with effacement of adjacent sulci, mild midline shift and adjacent leptomeningeal enhancement.There is a 15mm intraparenchymal hematoma at the medial right temporal lobe associated with mild uncal herniation.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.MRA brain:No significant narrowing is identified at the distal right ICA to suggest thrombus within the right ICA.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 a 4x2.5 mm ACOMA aneurysm present directed superiorly. The A1 segments are similar in diameter. The aneurysm originates from the left A1/A2 junction.The anterior communicating artery is small to medium sized. There is fetal origin of the PCA bilaterally with medium sized left p1 segment and hypoplastic right p1 segment.There is extracranial origin of the right PICA. The RVA is smaller than the LVA intracranially distal to the right PICA origin.
1.Multiple gray matter based foci of acute infarction in the right hemisphere.2.No evidence for thrombus at the distal right ICA.3.Although there is mild delay in perfusion to the non-infarcted portions of the right hemisphere, there is no significant difference in cerebral blood flow.4.Right subdural hematoma is stable.5.Right temporal lobe hematoma is stable.