Wk 5, Case 5 - Review

Patient History

A 69-year-old male with a history of prior stroke, chronic kidney disease, and polymyalgia rheumatica presents with new facial droop.

Findings

Brain: Diffusion restriction within the right globus pallidus/posterior limb of the internal capsule involving a very small area, which measures 5 x 3 mm.

Associated decreased ADC signal within this region when compared to the surrounding brain parenchyma. Region also demonstrates increased T2/FLAIR signal and T1 hypointense signal.

Diffuse bilateral subcortical and periventricular white matter microangiopathic changes.

Ventricles are normal in size.

No acute intracranial hemorrhage or extra-axial collection. No mass lesions. No midline shift or mass effect.

Orbits: Orbits are normal.

Paranasal sinuses and mastoids: Visualized paranasal sinuses are clear.
Mastoid cells and auditory canal are unremarkable.

MRA and ASL: Expected flow voids in major vessels are present. Circle of Willis, anterior and posterior circulation are patent. No dissection, aneurysmal dilation or hemodynamically significant stenosis.

Dural arteriovenous fistula within the posterior cranial fossa, along the left tentorial leaflet with shunting on ASL.

Conclusion

1. New small infarct within the right globus pallidus/posterior limb of the internal capsule measuring up to 5 x 3 mm. This area demonstrates FLAIR hyperintense signal, elevated DWI, and decreased ADC signal. The presence of T1 hypointense signal at this location has been associated with infarction events of 16 hours and greater. Findings suggest acute to subacute infarction.

2. Circle of Willis, anterior and posterior circulation are patent. No dissection, aneurysmal dilation or hemodynamically significant stenosis.

3. Dural arteriovenous fistula within the left posterior cranial fossa.