Case 3 - Old and New Strokes: Cardioembolic Phenomenon

Dr. Yousem has provided the following report as a sample report for your reference. It does not match the case reviewed in the video.

EXAM: MRI BRAIN WASSERMAN PROTOCOL

INDICATION: Preoperative planning for a 74-year-old male with recurrent infarctions of unknown etiology.

Technique: A three-dimensional time-of-flight MR angiogram was acquired through the intracranial arteries followed by DWI and SWI acquisitions through the brain. Coronal 3-dimensional high isotropic resolution Black blood MRI images were acquired through the intracranial arteries. After a precontrast mask sequence was acquired, 0.1 mmol per kilogram of a gadolinium-based contrast agent was administered and a three-dimensional contrast-enhanced MR angiogram was acquired during arterial and venous and delayed venous phases. Coronal and axial 3-dimensional high isotropic black blood MRI images were acquired through the intracranial arteries, with high-resolution two-dimensional cardiac gated black blood MRI images acquired through intracranial vessels of interest. MIP images were reconstructed from the MRA data sets. ADC maps were constructed from the axial diffusion weighted scans after 3D post-processing from raw data. No immediate complications were noted.

COMPARISON: MRI BRAIN dated 12/21/2019, MRI BRAIN WASSERMAN PROTOCOL dated 11/25/2019 .

FINDINGS:

There are multiple scattered foci of diffusion restriction indicating acute/subacute infarcts, new from the prior examination on 12/21/2019, including along the bilateral superior frontal convexities, and possibly involving the cerebellar vermis, and medial posterior aspect of the left cerebellar hemisphere.

Interval evolution of the prior infarctions with more well developed encephalomalacia and gliotic changes seen involving the left middle and inferior gyri, and the right parietal lobe.

There are numerous areas of parenchymal microhemorrhages along the superficial aspects of the bilateral cerebral hemispheres with a predominance along the superior frontoparietal regions and medial parietal and occipital lobes.

Multifocal areas of nonvascular superficial parenchymal enhancement as well as perivascular enhancement involving small vessels are seen.

Along the superior surface of the left middle frontal gyrus there is a lobular serpiginous focus of enhancement measuring approximately 7 x 4 x 4 mm (series 39 image 63), which does not convincingly correspond to a vessel, microhemorrhage, or subacute infarct. However, it could represent enhancement within an expanded occluded vessel, possibly a superficial vein.

There are also multiple areas of perivascular enhancement seen along the bilateral convexities, including within a sulcus along the medial aspect of the left middle frontal gyrus (series 39 image 63, series 34 image 72) and the dorsal surface of the right precentral gyrus (series 41 image 26, series 34 image 51). Other areas suspicious for small vessel enhancement include over the left inferior parietal lobe (series 34, image 17).

There are foci of cortical surface enhancement seen such as over the left inferior parietal lobe (series 34, image 21) and left posterior frontal lobe cortex (series 34, image 57).

There are numerous foci of hypointensity with surrounding enhancement seen involving the right superior parietal lobe (series 39, images 7 through 28); however, these appear to correspond primarily with microhemorrhages with surrounding enhancement rather than small vessels with perivascular inflammation.

Mild generalized volume loss is similar. There is no hydrocephalus or extra-axial fluid collection.

Redemonstration of bilateral prominent ophthalmic artery infundibula (left greater than right) and posteriorly projecting clinoid segment ICA aneurysms measuring 3 mm on the left and 1 mm on the right, without substantial change from the MRA from

11/25/2019.

No new aneurysm or large vessel stenosis is seen.

IMPRESSION:

1. Multifocal superficial parenchymal enhancement in a nonvascular distribution along the cortical surface of the cerebral hemispheres in addition to areas of perivascular enhancement with the differential including intravascular lymphoma, sarcoidosis with vascular involvement, or primary angiitis of the CNS. A candidate for biopsy is the 7 mm focus of superficial parenchymal enhancement involving the left middle frontal gyrus. This does not definitively correspond with a lumen on the high-resolution

MR angiogram, although that could be a feature of intravascular lymphoma. The numerous microvessels support a small vessel vasculopathy.

2. Multiple scattered foci of acute/subacute infarcts, new from the prior examination on 12/21/2019 within the bilateral superior frontal lobes and possibly cerebellum. Expected evolution of the prior areas of infarction.

3. Stable small bilateral paraclinoid ICA aneurysms with prominent ophthalmic artery infundibula.