Wk 4, Case 5 - Review

Patient History

A 58-year-old female with history of epilepsy presents with stroke-like symptoms.

Findings

CT Head and CT Perfusion:

Periventricular hypoattenuation, nonspecific finding, most commonly due to chronic microvascular ischemic disease. Additional areas of encephalomalacia involving the right temporal lobe with additional gliosis.

Streak artifact partially obscures evaluation of the occipital lobes bilaterally.

Prominence of the lateral ventricles bilaterally.

Enlarged partially empty sella.

Carotid artery calcifications involving the cavernous and into the internal carotid arteries bilaterally.

No evidence of acute intracranial hemorrhage. No extra-axial fluid collection or midline shift.
Orbits are symmetric and within normal limits. Visualized paranasal sinuses are clear. Trace bilateral mastoid effusions.

CT perfusion images demonstrate subjectively reduced mean transit time, reduced time-to-maximum, increased cerebral blood flow, and increased cerebral blood volume involving the right temporal cortex and extending to the right parietal and occipital cortex.

MRI Brain and MR Perfusion:

Cortical restricted diffusion in the right parietal, temporal, and occipital lobes with associated FLAIR signal abnormality. No susceptibility artifact to suggest hemorrhage. MR perfusion images demonstrate decreased TTP with slightly elevated relative CBF and CBV, suggesting increased perfusion compared to the contralateral unaffected side.

No intracranial mass or mass effect. No abnormal intracranial enhancement. Scattered and confluent T2/FLAIR hyperintensities in the subcortical and periventricular white matter as well as patchy foci in the pons and bilateral striatocapsular regions are nonspecific, but likely represent the sequela of chronic microangiopathic ischemic change.

Encephalomalacia and gliosis in the right temporal lobe with associated ex vacuo dilatation of the right temporal horn. Bilateral temporal encephaloceles. Right occipital lobe encephalomalacia.

Underlying parenchymal volume loss, with prominence of the lateral ventricles.

Cerebellar tonsils are in normal position. Sella is expanded and mostly empty, filled with CSF.

Major intracranial arterial and venous flow voids are preserved.

Orbital contents appear normal. Paranasal sinuses are clear. Trace right mastoid fluid.

Conclusion

CT Head and CT Perfusion:

1. No CT evidence of acute intracranial abnormality.

2. No evidence of territorial infarction.

3. Mildly decreased mean transit time and time to maximum with increased cerebral blood volume and increased cerebral blood flow involving the right temporal cortex and extending to the right parietal and occipital lobes. This is compatible with ongoing seizures or status epilepticus.

MRI Brain and MR Perfusion:

1. Cortical restricted diffusion in the right parietal, temporal, and occipital lobes, corresponding to slightly elevated perfusion. Findings are most compatible with recent seizure rather than ischemic infarct. No evidence of hemorrhage.

2. Bilateral temporal encephaloceles.

3. Parenchymal volume loss and chronic small vessel ischemic disease. Right temporal and occipital encephalomalacia.