Wk 7, Case 4 - Review

Patient History
53-year-old man with "transient ischemic attack "

MRI brain without contrast:

Findings
Triangular focus of restricted diffusion in the superior right periatrial region for instance with a smaller more subtle focus in the left parietal subcortical region. Moderate to marked scattered periventricular and subcortical T2 FLAIR hyperintensities. Focus of cystic encephalomalacia in the right thalamus. The major intracranial flow voids are patent. Visualized paranasal sinuses and mastoid air cells are clear. No pathologic increased susceptibility.

Impressions
Irregular focus of restricted diffusion in the right periatrial region and small rounded focus of restricted diffusion in the left parietal subcortical region. Moderate nonspecific subcortical and periventricular T-2 FLAIR hyperintensities with focus of cystic leukomalacia in the right thalamus. Overall, findings could reflect recent ischemia superimposed on chronic small vessel ischemic disease in the appropriate clinical context. Vasculopathy or inflammatory/demyelinating disease could also be considered appropriate clinical context.

MRA of the head:

Findings
Both vertebral arteries, the basilar artery, and both carotid arteries are patent. There is a small fenestration in the proximal basilar artery. The patient has prominent posterior communicating arteries, right greater than left with a hypoplastic right P1 segment. There is focal dilatation of the right middle cerebral artery within the sylvian portion over a segment measuring approximately 1.8 cm. There are no outpouchings from this dilated segment however. A small area of narrowing of the right middlecerebral artery as it enters the sylvian fissure can be seen. The left middle cerebral artery is unremarkable.

The anterior cerebral artery branches show focal areas of narrowing in the pericallosal portion and there is very slight narrowing of the midpoint of the right anterior cerebral artery A1 segment. Within the middle cerebral artery branches on the right side there are areas of vascular narrowing is well.

Slight irregularity in caliber of the left posterior cerebral artery is noted and there are distal right posterior cerebral artery vascular narrowings as well. The right posterior inferior cerebellar artery also shows slight irregularity.

Impressions
Areas of vascular dilatation in the right middle cerebral artery sylvian portion as well as areas of focal vascular narrowing in the anterior cerebral artery branches and middle cerebral artery branches and posterior cerebral artery branches, asymmetric in distribution. Suggest clinical correlation for vasculitis or vascular dysplasia. Conventional arteriography may be useful.