Case 12 - Horner's Syndrome, MS, Dissection

Dr. Yousem has provided the following report as a sample report for your reference. It does not match the case reviewed in the video.

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Crescentic T1 and T2 hyperintense signal along the distal left cervical internal carotid artery as it enters the skull base corresponds to an intramural hematoma in the setting of an acute dissection. The dissection flap extends to the proximal lacerum segment without involvement of the petrous segment.

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EXAM: MRI C-SPINE W/WO CONTRAST, MRA NECK W/WO CONTRAST, MRI BRAIN W/WO CONTRAST, MRA HEAD WO CONTRAST

INDICATION: 53 years old Female presents with history of L sided horner syndrome

TECHNIQUE: Multiplanar multisequence magnetic resonance imaging of the brain before and after the administration of IV contrast was performed. ASL perfusion imaging was performed. 3-D time-of-flight MRA of the brain and the bilateral carotid bulbs was performed. Precontrast imaging and postcontrast MRA of the neck was performed. MIP/3-D postprocessing was performed. Multiplanar, multisequence resonance imaging of the cervical spine was obtained with and without intravenous contrast.

Contrast: 6.5 cc IV Gadavist

COMPARISON: Brain and C-spine MRI 8/10/2020

Brain:

No acute ischemia. No hydrocephalus. No significant mass effect.

There is one tiny focus of contrast enhancement seen on series 55 image 28 in a left medial frontal white matter demyelinating plaque measuring 1 to 2 mm in size. This area was enhancing on the prior study from August 10, 2020.

Unchanged periventricular, juxtacortical and subcortical T2/FLAIR hyperintense lesions, a number of which are perpendicularly oriented along the lateral ventricles. Questionable tiny lesion along the ventral aspect of the aqueduct in the midbrain (series 29 image 9, likely present on prior studies as seen on series 3 image 11 on study from 8/10/2020. High signal intensity is also seen at the cervical medullary junction on series 29 image 2 more on the left side than the right side.

Grossly normal flow-related signal in the major intracranial arteries and the dural venous sinuses.

Grossly unremarkable appearance of the orbits.

No substantial paranasal sinus disease. Left mastoid effusion.

No suspicious osseous lesions.

Unremarkable ASL imaging with grossly symmetric and normal-appearing perfusion maps.

MRA Brain:

Anterior Circulation: No high grade stenosis or occlusion. Minimal 1 to 2 mm outpouching which appears to give rise to the posterior communicating artery on the right side, likely an infundibulum.

Posterior Circulation: No high grade stenosis or occlusion.

MRA neck:

Carotids: No high grade stenosis or occlusion.

Vertebrobasilar: No high grade stenosis or occlusion.

Additional findings: None.

C-spine:

No acute fracture. No malalignment. Vertebral body heights maintained. No suspicious marrow replacing lesions.

Unchanged small T2 hyperintense lesions in the cervical cord, such as a central/ventral cord at C2, central posterior cord at C3, the left hemicord at C3-C4, central posterior cord at the C4-5 disc level, the right hemicord at C6-C7, central posterior cord at the C5-6 disc level, right lateral cord at the C6-7 disc level and the left hemicord at T1. No abnormal contrast enhancement.

Soft tissues: Grossly unremarkable.

Degenerative changes:No substantial spinal canal or neural foraminal stenosis.

Additional Findings: None.

IMPRESSION:

1. Similar appearance of the brain and cervical spine compared to prior, with multiple white matter lesions compatible with history of multiple sclerosis. No definite new lesions and no enhancing lesions identified. No specific findings to explain the

patient's possible Horner syndrome. Persistent punctate enhancement of one left medial deep white matter plaque.

2. Unremarkable MRA of the brain and neck.