Wk 3, Case 4 - Review

Patient History
70 yo woman with visual disturbance, b/l cataracts, HTN, HLD, CAD (MI s/p stent '13), who presents to ED with 3d of gradual onset right-sided weakness and numbness.

Findings
MR brain:

No diffusion restriction is identified. Redemonstration of the foci of T2/FLAIR hyperintensity within the central pons and midbrain. Mild periventricular and subcortical white matter T2/FLAIR hyperintensity , nonspecific and likely sequelae of chronic microvascular ischemic changes . Unchanged appearance of the angle of vessels along the right inferior frontal lobe. Chronic infarct of the left cerebellum. The ventricles are normal in size and symmetric. The basilar cisterns are patent. No extra-axial fluid is identified. No intracranial hemorrhage is present. No mass effect or midline shift is identified. The major intracranial vascular flow voids are preserved. No abnormal parenchymal or meningeal enhancement is present. The paranasal sinuses are clear. No mastoid effusion is identified.

MR orbits:

There is mild persistent hyperintensity in the left optic nerve, as best seen on the coronal T2-weighted sequences. No abnormal enhancement is identified. The extraocular muscles are normal in size and symmetric. Bilateral lacrimal glands are unremarkable. No proptosis is present.

MR cervical spine:

Focus of apparent enhancement is identified in the right aspect of the anterior medulla on the sagittal post contrast sequences, not appreciated on the axial images and related to partial volume averaging from adjacent enhancing vessels. Areas of T2/FLAIR hyperintensity are identified within the central cord extending from the craniocervical junction to approximately C3-C4, smaller in craniocaudal and axial extension compared to prior exam (previously extended to level of C4-C5 ). There is persistent ill-defined patchy enhancement in the upper spinal cord at the level of C2 . No additional abnormal signal intensity is identified in the spinal cord. Mild degenerative changes in the cervical spine appear unchanged. Partial retropharyngeal course of the internal carotid arteries. Mildly prominent adenoid tissue.

Impressions
Multifocal brainstem areas of abnormal signal intensity without enhancement. Chronic small vessel ischemic changes in the white matter. 2. Long segment intramedullary lesion involving the upper cervical spinal cord and cervicomedullary junction with mild degree of enhancement compared to prior exam.