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MRI Cerebral Angiography Stroke Symptoms 160617 After EGD Dilation F
1203 -
1203 - ..
1204 - Summary/Objective
1205 -
120501 - Follow up ref SDS 5 0000.
120502 -
120503 -
120505 - ..
120506 - [On 160621 1024 letter to Doctor Yoo notifies medical team
120507 - of progressing stroke-like symptoms following EGD Dilation
120508 - procedures today, on 160617. ref SDS 7 D961
120509 -
120510 -
120511 -
120512 -
120514 - ..
1206 -
1207 -
1208 - Progress
1209 -
120901 - Yesterday morning on 160617, had EGD dilation procedure at GI Clinic
120902 - VA Medical Center in Sacramento. Later suffered stroke symptoms of
120903 - left side weakness and partial vision loss, reported on 160617 1637.
120904 - ref SDS 5 5F6F
120906 - ..
120907 - In the late evening on 160617, went to VA Medical Center in San
120908 - Francisco and was examined in the ER. ref SDS 5 0179
120910 - ..
120911 - Doctor Abrams, Chief of Neurology was notified, and ordered initially
120912 - CT of brain, then an MRI of the brain, also called MRA for cerebral
120913 - angiography.
120915 - ..
120916 - Seems like this was done last night on 160618, about 0300, reported in
120917 - the record yesterday on 160617 1637. ref SDS 5 027K
120919 - ..
120920 - Gearview.exe MRA scan files from are stored in...
120921 -
120922 - Note this will not open in Windows 10, needs Windows 7...
120923 -
120924 - F:\05\00003\SM\CC\GMPF\GFJ\20160718-134858\GEARView.exe
120926 - ..
120927 - Neuroradologist's report is stored in...
120928 -
120929 - Note MRI report follows report on CT scan...
120930 -
120931 - F:\05\00003\SM\CC\AGMJ\20160618-104000\welch.pdf
120932 -
120933 - 1. MRI 3D RECONSTRUCTION, AT SCANNER
120935 - ..
120936 - Proc Ord: MRI STROKE PROTOCOL
120937 - Exm Date: JUN 18, 2016@10:40
120938 - Req Phys: YOO,ALEXANDER Pat Loc: 2B(3)M/06-20-2016@10:36
120939 - Img Loc: MRI
120940 - Service: GENERAL INTERNAL MEDICINE
120941 -
120942 - (Case 1712 TRANSCRI) MRI BRAIN W&W/O GAD (MRI Detailed) CPT:70553
120943 - Contrast Media : Gadolinium
120945 - ..
120946 - Reason for Study: Evaluate for ischemic lesion; neglect
120947 - on exam
120948 -
120949 - (Case 1713 TRANSCRI) MRA INTRACRANIAL W/O GAD (MRI Detailed) CPT:70544
120950 -
120951 - (Case 1714 TRANSCRI) MRA NECK W/GAD (MRI Detailed) CPT:70548
120952 - Contrast Media : Gadolinium
120953 -
120954 - (Case 1716 TRANSCRI) MRI 3D RECONSTRUCTION, AT SCANNER(MRI Detailed) CPT:76376
120955 -
120957 - ..
120958 - 2. Clinical History:
120959 -
120960 - 1. Does the patient have one of the following
120961 - devices?:No
120962 - - cardiac pacemaker
120963 - - cardiac defibrillator
120964 - - implanted device or pump
120965 - - neurostimulator
120967 - ..
120968 - 2. Has this patient had surgery for a brain
120969 - aneurysm?:No
120971 - ..
120972 - 3. Will this patient need sedation?:No
120973 - - Sedation orders are the responsibility of the ordering
120974 - provider and should be placed at the time of imaging
120975 - request.
120977 - ..
120978 - 4. Is there anything within this patient that you are unsure
120979 - about in regards to MR safety?: (foreign body, metal
120980 - object, etc):
120981 - No
120982 - - If yes, please put in a short description below:
120984 - ..
120985 - 3. Report Status: Released/Not verified Date Reported: JUN 20, 2016
120987 - ..
120988 - 4. Report:
120989 -
120990 - 1. MR, MRA brain, carotid MR angiogram.
120991 -
120992 - 2. Technique: MRI of the brain was performed on a 1.5/3T MR
120993 - scanner with the following sequences: Multiplane
120994 - localizers, Sagittal T1, Axial FLAIR, Axial MPGR, Axial
120995 - HASTE, Axial diffusion weighted imaging, Coronal T2 turbo
120996 - spin echo. MRA of head and neck using time of flight
120997 - technique and IV administration of contrast with MIP
120998 - reformats. Precontrast axial 2 D and 3-D time-of-flight
120999 - MRA with MIP reformats, followed by postgadolinium coronal
121000 - MRA of head and neck using time of flight technique and IV
121001 - administration of contrast with MIP reformats.
121003 - ..
121004 - 3. Findings:
121005 -
121006 - 1. MRI brain:
121007 -
121008 - 1. No hemorrhage, herniation hydrocephalus.
121010 - ..
121011 - 2. Right superior cerebellar focus of reduced
121012 - diffusion, without significant hypointensity on ADC
121013 - map. There is associated focal FLAIR signal
121014 - hyperintensity and enhancement compatible with a
121015 - likely subacute right SCA territory infarct.
121017 - ..
121018 - [On 160802 1404 Doctor Massa called during meeting with
121019 - Stanford Neuroscience and advised VA Neurology no longer
121020 - believes the MRI scan on 160617, supports a finding nor
121021 - diagnosis of stroke. ref SDS 10 4C94
121023 - ..
121024 - [On 160802 1404 at 2024 after returning home from Stanford
121025 - Neuroscience Health Center in Palo Alto, received letter
121026 - from Doctor Massa presenting more details explaining new
121027 - efforts of the VA Neurology Department to review this case,
121028 - ref SDS 10 UH5L, and then determining that the MRI on
121029 - 160618, does not support a diagnosis of stroke. ref SDS 10
121030 - 5K34
121032 - ..
121033 - Which scan shows this?
121035 - ..
121036 - MRI report continues...
121037 -
121038 - 3. Diffuse right holohemispheric subarachnoid
121039 - enhancement, predominantly in the right frontal and
121040 - right occipital lobes.
121042 - ..
121043 - Which scan shows this?
121045 - ..
121046 - MRI report continues...
121047 -
121048 - 4. Paranasal sinuses are clear. The orbits are
121049 - unremarkable. Flow voids are intact.
121050 -
121052 - ..
121053 - 2. MRA:
121054 -
121055 - 1. No hemodynamically significant stenosis. Likely
121056 - left anterior choroidal artery infundibulum. Fetal
121057 - type right PCA.
121059 - ..
121060 - Which scan shows this?
121061 -
121062 - [On 160715 1630 Doctor Yoo Neurology Progress Notes say in
121063 - part "given absence of vertebrobasilar disease..." which is
121064 - another way of saying there is no evidence of
121065 - atherosclerosis in the brain. ref SDS 8 TV4F
121067 - ..
121068 - Research finds...
121069 -
121070 - Radiopaedia.org
121071 -
121072 - Anterior choroidal artery
121073 -
121074 - http://radiopaedia.org/articles/anterior-choroidal-artery
121076 - ..
121077 - The anterior choroidal artery (AChA) supplies several crucial
121078 - anatomical structures of the brain important for vision and
121079 - motor control. Identification of AChA is important because of
121080 - its strategic and extensive area of supply as well as large
121081 - variations in the territorial distribution.
121083 - ..
121084 - "Infundibulum" seems to be a buildup or swelling, as if blood flow
121085 - might be restricted.
121086 -
121087 - [On 160722 1304 meeting with Doctor Massa, attending
121088 - physician in the case, advises Neurology believes short
121089 - term vision and motor control impairment could not have
121090 - been caused by deficit identified in MRI because, an
121091 - obstruction at the location identified in the MRI would
121092 - have caused more stroke symptoms than those presented by
121093 - the patient to the ER on 160617. ref SDS 9 A66O
121095 - ..
121096 - What can cause this?
121098 - ..
121099 - What etiologies cause "left anterior choroidal artery infundibulum."
121101 - ..
121102 - Another source says...
121103 -
121104 - Intracranial aneurysms-Pathogenesis & Surgery:
121105 -
121106 - Anterior Choroidal Artery:
121107 -
121108 - http://www.thamburaj.com/intracranial_aneurysms.htm
121110 - ..
121111 - In its course through the carotid cistern it supplies, through
121112 - perforating branches, to inferior chiasm, parts of optic tract
121113 - & globus pallidus, the genu of the internal capsule, part of
121114 - cerebral peduncle, red nucleus, the subthalamus and thalamic
121115 - nuclei and further distally, to lateral geniculate body, the
121116 - internal capsule and the optic radiations. Obviously loss of
121117 - this vessel is devastating.
121119 - ..
121120 - The record on 160617 shows that after EGD dilation left side motor
121121 - control (weakness) and partial vision loss occurred. 160617 1637,
121122 - ref SDS 5 5F6F
121124 - ..
121125 - Some vision impairment was still present in the ER later that night on
121126 - 160617 1637. ref SDS 5 LH4J
121127 -
121129 - ..
121130 - MRI report continues...
121131 -
121132 - 2. Aortic arch and branch vessels are patent.
121134 - ..
121135 - This is a form of finding no evidence of atherosclerosis obstructions
121136 - anywhere in the cerebral blood vessels.
121138 - ..
121139 - Aligns with CCTA finding no evidence of atherosclerosis, reported on
121140 - 151019 0930. ref SDS 1 SU62
121141 -
121142 - [On 160618 0800 during meeting in ER examination room,
121143 - asked Doctor Yoo if the MRI shows any evidence of
121144 - atherosclerosis, and he advised the MRI scans show blood
121145 - vessels appear clear of obstructions. ref SDS 6 UQ5N
121147 - ..
121148 - [On 160715 1630 Doctor Yoo Neurology Progress Notes say in
121149 - part "given absence of vertebrobasilar disease..." which is
121150 - another way of saying there is no evidence of
121151 - atherosclerosis in the brain. ref SDS 8 TV4F
121153 - ..
121154 - [On 160805 0845 follow up MRI of brain to assess continuing
121155 - stroke symptoms, made similar findings to MRI on 160618, of
121156 - no evidence for atherosclerosis blockages of blood flow in
121157 - the brain. ref SDS 11 WQ7S
121159 - ..
121160 - [On 160817 0800 final MRI of brain checking for adverse
121161 - reactions to conscious sedation during EGD procedure the
121162 - day before, made similar findings of no evidence for
121163 - atherosclerosis blood flow blockages in the brain.
121164 - ref SDS 12 WQ7S
121166 - ..
121167 - [On 160820 0940 Stanford Neuroscience 2nd opinion section
121168 - on Diagnostic Data reports finding MRI shows no evidence of
121169 - atherosclerosis in the brain area. ref SDS 13 PW4G
121171 - ..
121172 - MRI report continues...
121173 -
121174 - 4. Impression:
121175 -
121176 - 1. Findings compatible with a likely subacute right SCA
121177 - territory infarct.
121179 - ..
121180 - What else are findings "compatible" with other than "subacute right
121181 - SCA territory infarct"?
121183 - ..
121184 - How "likely" are the findings to have found an actual infarct - 10%,
121185 - 50%, 90%.
121187 - ..
121188 - MRI report continues...
121189 -
121190 - 2. No hemodynamically significant stenosis.
121192 - ..
121193 - 3. Diffuse right holohemispheric subarachnoid enhancement
121194 - with several areas suspicious for leptomeningeal
121195 - enhancement. Correlate with lumbar puncture.
121196 - Alternative etiologies include a vascular shunting
121197 - lesion such as an occult dural fistula or arteriovenous
121198 - malformation. Correlate with conventional angiography
121199 - if clinically indicated.
121201 - ..
121202 - Preliminary findings of diffuse right holohemispheric
121203 - leptomeningeal enhancement were discussed with Dr Yoo
121204 - of Neurology at 1:30 PM on 6/19/16. Findings of right
121205 - SCA territory subacute infarct and consideration of
121206 - avascular shunting lesion were discussed with Dr Guo
121207 - by Dr Sonshine at 10:26 Am on 6/20/2016.
121208 -
121210 - ..
121211 - Has anything been discussed with the team on findings of "...likely
121212 - left anterior choroidal artery infundibulum," which might correlate
121213 - with loss of motor control and vision, per above? ref SDS 0 VN4G
121215 - ..
121216 - MRI report concludes...
121217 -
121218 - Primary Diagnostic Code:
121219 - Primary Interpreting Staff:
121220 - DAVID M WILSON, MD, PhD, ATTENDING NEURORADIOLOGY
121221 - Primary Interpreting Resident:
121222 - DANIEL SONSHINE, MD, RESIDENT-RADIOLOGY
121223 - VERIFIED BY:
121224 -
121225 - /DS
121226 -
121227 - *************************
121228 - * PRELIMINARY REPORT *
121229 - *(RELEASED/NOT VERIFIED)*
121230 - *************************
121231 -
121233 - ..
121234 - There is another report with the title...
121235 -
121236 - MRA NECK W/GAD
121237 - Proc Ord: MRI STROKE PROTOCOL
121238 - Exm Date: JUN 18, 2016@10:40
121239 - Req Phys: YOO,ALEXANDER
121241 - ..
121242 - This appears to be word for word identical to the MRI report above.
121243 - ref SDS 0 J49N
121244 -
121246 - ..
121247 - There is another report with the title...
121248 -
121249 - MRA INTRACRANIAL W/O GAD
121250 - Proc Ord: MRI STROKE PROTOCOL
121251 - Exm Date: JUN 18, 2016@10:40
121252 - Req Phys: YOO,ALEXANDER
121254 - ..
121255 - This appears to be word for word identical to the MRI report above.
121256 - ref SDS 0 J49N
121257 -
121259 - ..
121260 - There is another report with the title...
121261 -
121262 - MRI BRAIN W&W/O GAD
121263 - Proc Ord: MRI STROKE PROTOCOL
121264 - Exm Date: JUN 18, 2016@10:40
121265 - Req Phys: YOO,ALEXANDER
121267 - ..
121268 - This appears to be word for word identical to the MRI report above.
121269 - ref SDS 0 J49N
121270 -
121271 -
121272 -
121273 -
121275 - ..
121276 - When did stroke occur???
121278 - ..
121279 - Research found...
121280 -
121281 - Quality Improvement
121282 -
121283 - RSNA Radiographics
121284 -
121285 - Sequence-specific MR Imaging Findings That Are Useful in
121286 - Dating Ischemic Stroke
121287 -
121288 - http://pubs.rsna.org/doi/full/10.1148/rg.325115760
121289 -
121290 -
121291 -
121292 -
121293 -
121294 -
121295 -
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121299 -
1213 -