Case 1

This is a brain MRI study showing patchy FLAIR and T2 hyperintensities involving the cortical and subcortical regions, as well as the peri-ventricular / deep white matter in a distribution limited to the right MCA vascular territory (mostly right parieto-fronto-temporal). The same areas appear bright on the DWI series and correspondingly low on the ADC map, indicating restricted diffusion due to cytotoxic oedema. On the Time of Flight series, I can appreciate stenosis and irregularity of the M1 segment of the right MCA, and no flow in the M2 / M3 segments.

Absence of blooming artifact on the susceptibility weighted imaging rules out haemorrhagic transformation. There is no evidence of dissection of the right intracranial internal carotid artery on the T1 series.

The features are in keeping with acute arterial ischaemic infarction; the patchy rather than confluent distribution points away from complete thrombotic occlusion of a large vessel. The features of the right MCA are characteristic of vasculitis. The overall picture is of neurovasculitis causing acute infarction. A CT angiography study may be useful to further demonstrate the arterial pathology; alternatively, a conventional cerebral angiography study may be performed.

I would urgently convey the findings to the referring physician for possible immediate treatment by thrombolysis, and suggest discussion at the relevant MDT.