 Redemonstrated are numerous, scattered areas of T2 hyperintensity throughout the supratentorial white matter with particular prominence at the level of the peri-atrial regions and additional conspicuous areas of subcortical signal abnormality which spares the cortex, including in the anterior temporal poles. Also involved is the subinsular white matter and notably the subcortical white matter of the paramedian superior frontal lobes. These are not significantly changed in appearance. Note is again made of diffusely prominent perivascular spaces.No restricted diffusion is present to indicate an acute ischemic event. No susceptibility weighted abnormalities to indicate hemorrhage. The ventricles and sulci are unchanged in size or shape without dilatation. There are no masses, mass effect or midline shift. There are no extraaxial fluid collections or subdural hematomas. Flow voids are present within the major vessels indicating patency. The paranasal sinuses and mastoid air cells are clear.
Unchanged extensive parenchymal signal abnormality which is somewhat unique in that it involves the subcortical white matter, sparing the cortex, as well as the anterior temporal poles and paramedian superior frontal lobes. The pattern is atypical for routine age-related small vessel disease. There are, however, some features which are fairly specific for CADASIL. Other atypical vascular etiologies may also be considered such as vasculitis. The pattern is not typical for demyelinating disease.