Wk 3, Case 2 - Review

Patient History
Worsening vision. History of recent stroke. Right leg difficulty. Encephalopathic.

Findings
These images demonstrate areas of restricted diffusion in the right temporal lobe, the right occipital lobe, the right posterior frontal lobe, the right parietal lobe, the left perirolandic area, the left anterior frontal lobe, and the left parietal lobe. There is encephalomalacic changes with laminar necrosis in the left parietal-occipital lobe as well. The periphery of the left temporal lobe also shows high signal intensity changes. When compared to the previous evaluation the medial extent of the right parietal area of cytotoxic edema has increased. There is new right occipital cortical restricted diffusion seen best on series 7 image 41 when compared to prior study.

Extension of cortical restricted diffusion to the periinsular region anteriorly seen on series 7 image 40 is also seen. The involvement of the left hemisphere shows minimal increased left frontal cortical ribbon of restricted diffusion when comparing series 7 image 43 with the prior study, series 5 image 54. The cortical laminar necrosis is unchanged on the left side. There appears to be slightly greater amount on series 37 image 26 currently than previously in the right inferior frontal lobe. The volume of brain tissue right in signal intensity on FLAIR scans has also increased in the interval with the exception of the gyrus rectus region on the left side which has improved slightly and the cingulum on the left side which has improved slightly when comparing current series 6 image 17 and previous series 12 image 17.

MR angiographic images of the brain show patent major vessels without areas of occlusion.

Impressions
Interval increase in the areas of restricted diffusion affecting the right occipital lobe and parietal lobe and left frontal lobe compared with prior examination of May 10, 2018. Interval slight improvement in the inferior medial left frontal lobe FLAIR signal abnormality in the interval. The findings comport with the clinical diagnosis of MELAS syndrome.No change in the intracranial MRA and neck MRA which are both normal.