Wk 3, Case 3 - Review

Patient History

Patient with a history of atrial fibrillation on Coumadin presents with new left-sided facial droop and slurred speech.

Findings

MRI Brain:

The ventricles and sulci are prominent, compatible with diffuse brain parenchymal volume loss. There is no midline shift. Diffusion-weighted images with postprocessed ADC map demonstrate a 1.8 cm linear region of restricted diffusion involving the right frontal lobe precentral gyrus without underlying FLAIR hyperintensity, most compatible with infarct within a hyperacute timeframe.

Perfusion weighted imaging demonstrates an associated abnormality with Tmax >4 sec of 11ml. No measurable region of ADC <620 or Tmax >6 sec. No evidence of hemorrhagic transformation. There is a punctate focus of susceptibility within the right temporal lobe, likely representing chronic microhemorrhage.

Underlying moderate periventricular and subcortical white matter FLAIR hyperintensity are nonspecific but likely represent chronic small vessel ischemic changes. Similar changes involving the bilateral basal ganglia and thalami are also noted. There is a small chronic lacunar infarct involving the left corona radiata. Postcontrast images demonstrate no abnormal enhancement within the brain parenchyma.

There is trace fluid within the left sphenoid sinus. There is minimal mucosal thickening involving the ethmoid air cells. Patient is status post bilateral orbital lens surgery. The mastoid air cells are clear. Incidental note is made of a 1 cm cyst in the nasopharynx. Additionally, there is a 1.3 cm cystic lesion in the right maxilla, likely associated with a tooth root and likely representing dental disease.

MRA Brain:

Bilateral distal internal carotid arteries are patent with mild irregularity and narrowing. The bilateral M1 segments are normal in caliber. There is severe stenosis of the proximal right M2 segment inferior division. There is multifocal moderate narrowing of the M2 segments of the left middle cerebral arteries.

The anterior cerebral arteries are patent with hypoplasia of the right A1 segment.

There is multifocal moderate narrowing of the posterior cerebral arteries. The basilar artery is patent. The left vertebral artery is dominant. The right vertebral artery is hypoplastic and demonstrates multifocal moderate to severe narrowing.

No aneurysm seen greater than 3 mm.

Conclusion

1. Small linear hyperacute infarct involving the right frontal lobe precentral gyrus. No severe mass effect or hemorrhagic transformation. Associated mild perfusion abnormality of Tmax >4 sec volume of 11ml.

2. Moderate periventricular and subcortical white matter chronic small vessel ischemic changes. Similar changes involving the bilateral thalami and basal ganglia. Chronic small infarct in the left corona radiata with minimal chronic hemorrhage.

3. Severe stenosis of the proximal M2 segment right middle cerebral artery. Multifocal moderate narrowing of the M2 segment left middle cerebral artery. Hypoplastic right vertebral artery with multifocal moderate to severe narrowing. Multifocal moderate narrowing of the bilateral posterior cerebral arteries.