Wk 5, Case 2 - Review

Patient History

Altered mental status.

Findings

CT Head:

No CT evidence of acute intracranial hemorrhage. No abnormal extra-axial fluid collection. No acute herniation.

No mass, mass effect, or midline shift as measured at the level of septum pellucidum.

Brain parenchyma demonstrates no acute loss of gray-white differentiation within the cortical or deep structures.

Size and configuration of the ventricular system is normal.

Basal cisterns are patent.

No acute osseous abnormality of the calvarium. No extracalvarial soft tissue abnormality.

CT Perfusion Head:

Subtle asymmetry with increased MTT and Tmax in the left temporal lobe with possible subtle decreased CBF and CBV.

No other areas of asymmetry or focal abnormalities.

CTA Head and Neck:

Normal takeoffs of the vertebral arteries and common carotid arteries bilaterally.

Normal appearance of the cervical segments of the vertebral arteries.

Common carotid arteries are normal and patent in their course. Normal appearance of the carotid bifurcations.

Cervical and petrous segments of the internal carotid arteries are symmetric and patent bilaterally.

No evidence of large vessel occlusion, aneurysm, or dissection in the vessels of the neck.

Contrast opacified jugular veins are within normal limits.

Petrocavernous and supraclinoid ICA segments are normal. MCA and ACA branches are normal without evidence of stenosis or aneurysm. ACOM is present.

Vertebral arteries and cerebellar arteries are patent. Basilar and bilateral posterior cerebral arteries are patent without evidence of stenosis or aneurysm.

Dural venous sinuses are patent without evidence of thrombosis or high-grade stenosis.

MRI:

Brain Parenchyma: Abnormal tissue along the left temporal horn following the cortical signal intensity on all sequences measuring 16 x 8 x 7 mm (anterior posterior by transverse by craniocaudal dimension)

Additional small nodular abnormal signal intensity immediately lateral to this area measuring up to 4 x 3 mm. Nonspecific 4 mm T2/FLAIR hyperintense focus in the subcortical white matter deep to the right inferior frontal gyrus pars orbitalis. No evidence of hippocampal sclerosis; specifically, normal signal intensity, morphology/architecture and volume of the hippocampal formations and amygdalae bilaterally. No hemosiderin deposition or calcifications. No evidence of skull base meningoencephalocele.

No hemorrhage, acute infarction, mass effect, or midline shift.

Ventricles and Sulci: Normal for age.

Extra-Axial Spaces: No extra-axial fluid collection.

Vascular Structures: Major intracranial vascular flow voids are maintained.

Paranasal Sinuses: No significant mucosal thickening or secretions.

Mastoid Air Cells: No effusion.

Orbits: No orbital pathology.

Cranium and Bones: No bony lesion.

Other: 7 mm well-circumscribed thin walled cyst in the left para midline nasopharynx, likely representing a Tornwaldt cyst. Nonspecific prominence of the nasopharyngeal adenoids.

Conclusion

1. CT perfusion study demonstrating subtle asymmetry in the left temporal lobe not appearing in a particular vascular territory. Given the patient's history of seizure, this apparent perfusion abnormality may relate to sequelae of post ictal state. No concordant abnormality on noncontrast imaging or CTA to suggest large vessel occlusion.

2. Gray matter heterotopia along the subependymal aspect of the left temporal horn measuring up to 16 mm, as detailed above.

3. Nonspecific 4 mm T2/FLAIR hyperintense focus in the right anterior frontal lobe pars orbitalis subcortical white matter, which in this age group likely represents sequela of prior infectious/inflammatory changes.