Right ataxia. There are T2 hyperintense lesions within the left midbrain, pons, bilateral basal ganglia, as well as the bilateral cerebral hemisphere white matter, predominantly in a periventricular distribution. There is no evidence of intracranial hemorrhage, mass, or acute infarct. There is no midline shift or herniation. The major cerebral flow voids are intact. There are secretions in the right sphenoid sinus. The orbits, skull, and scalp soft tissues are grossly unremarkable.
1. Bilateral basal ganglia and thalamic and right pons chronic lacunar infarcts and a background of chronic cerebral white matter small vessel ischemic disease, but no evidence of acute infarction.2. Findings suggestive of acute right sphenoid sinusitis.