Newly diagnosed presumed locally advance urothelial cancer with hypercalcemia. More lethargic today, worsening aphasia. There are areas of restricted diffusion and high T2 signal involving the right precentral and postcentral gyri measuring up to 30 mm. There are also punctate foci of restricted diffusion and high T2 signal involving the right lateral occipital lobe and bilateral anterior frontal lobes, including periventricular and subcortical white matter, as well as cerebral cortex. There is a small focus of encephalomalacia in the left basal ganglia. There is a diffuse background of cerebral white matter T2 hyperintensity bilaterally. There is a punctate focus of susceptibility effect in the left pons, which may represent a chronic microhemorrhage. There is no evidence of intracranial hemorrhage or mass. There is diffuse cerebral volume loss. There is no midline shift or herniation. The major cerebral flow voids are intact. The orbits, skull, paranasal sinuses, and scalp soft tissues are grossly unremarkable, aside from a small left frontal scalp lipoma and a small residual left parietal scalp hematoma.
1. Multiple subacute-appearing infarcts in the bilateral cerebral hemispheres, most notably involving the right precentral and postcentral gyri.2. Chronic left basal ganglia lacunar infarct and diffuse probable chronic small vessel ischemic disease.3. No evidence of intracranial metastases, although the assessment is limited without contrast.