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What Does The Following Brain MRI Report Suggest?

Posted on Tue, 12 Jul 2016

Question: I recently had an MRI/MRA of the brain and neck which indicated the following: 1) Chronic small vessel ischemic changes. Small focus of old infarction in the right cerebellar hemisphere measuring 8 mm x 2 mm in transverse dimension.
2) scattered atherosclerotic changes. Right vertebral artery appears 45% narrowed at the origin. The left vertebral artery is developmentally small and arises directly from the aortic arch. The left vertebral artery suspected to be moderately narrowed at the origin.
3) A 3 mm aneurysm projecting superolaterally from the intracranial left internal carotid artery in the paraclinoid region.
I am scheduled for rotater cuff surgery on 27 XXXXXXX 2016, should I inform the surgery of these findings.
4) Is the 45% narrowing something to be concerned about?
5) Doesn't it take more than just 3 mm aneurysm to be concerned?

Answered by Dr. Ishu Bishnoi (2 hours later)

Brief Answer:
Consultation

Detailed Answer:
Hi XXXX, thanks for asking from HCM.

I can understand your concern. The reason of small infarct in cerebellar hemisphere is vertebral artery and small arterioles atherosclerosis supplying this area. In your case, it is age related along with other positive factors (if any) like diabetes mellitus, hypertension, smoking, alcohol, family history.

As the narrowing of dominant vertebral artery (right) which mainly supplies cerebellum, is only 45%, there is no need to acute surgical/endovascular intervention is needed at present. But there is need to start
: Lipid lowering drugs especially cholesterol and triglycerides like Statins.
: Blood thinner drugs like Aspirin or Clopidogrel. Use of blood thinner drugs can increase chances of intracranial bleed or aneurysm rupture. And also if started before rotator cuff surgery, it can increase bleeding during surgery.

So risk versus benefit ratio should be taken into consideration. Opinions may vary from doctor to doctor. According to me, drugs can be started and stopped 3-7 days before surgery depending upon your bleeding profile reports.

Now coming to aneurysm risk of rupture which you must know. Aneurysmal rupture is a life threatening condition. In your case, good thing is that size is 3mm and there is no past history of rupture. So overall risk of rupture in you is around 0.1-0.15% in 10 years life span. There is no need of panic or worry. You can discuss it with neurologist.

You must tell about your reports to your treating surgeon and let them decide for you. He will ask you to take neurologist opinion before surgery to rule out any risk. According to me, you can be taken up for surgery under moderate risk of surgery which includes some risk due to aneurysm and ischemic changes.

Hope you got my point. If still in doubt, do let me know.

Thanks. Take care.

Above answer was peer-reviewed by : Dr. Nagamani Ng

Follow up: Dr. Ishu Bishnoi (6 hours later)

thank you for your candid comments. Since I do not smoke or drink and my Mother and older sister had TIAs, that may be more of a genetic thing. My appt with a neurologist is not until mid-July which will be after my surgery. My dr has me on Metform, Atorvastatin, Telemasartin-Hct and watching the diet. So, I believe I am well covered.
It's refreshing to know that I have an equal chance of having an aneurysm or a TIA. I prefer the aneurysm as that would be quicker...but we can't always choose, can we.
Have a good day.

Are there tests for bleeding profile reports or is this taken from a person's history of surgeries?

Answered by Dr. Ishu Bishnoi (1 hour later)

Brief Answer:
Thanks for appreciation and bleeding profile tests

Detailed Answer:
Hi XXXX, welcome back.

Thanks for the appreciation.

You are almost covered. But you have not been prescribed any blood thinner drug or anticoagulant. So ask your doctor to start one like Ecospirin or Clopidogrel etc.

Your aneurysm is of very small size. So there is very little chance of rupture as I have mentioned before. But you already have ischemic changes and there is narrowing, so there is more chance of new ischemic lesions or TIAs. You should avoid salt more than 2 g in day, reduce fat in diet, start morning walk, avoid mental stress/exertion, do Yoga or meditation.

For bleeding profile, there are few lab tests like
: Clotting time
: Bleeding time
: Prothrombin Time
: activated Prothrombin time
: platelet count
: aPTT
You can ask your doctor to get all these tests done to find any bleeding abnormality.

Hope it will help you. Still in doubt, do let me know.

Thanks. Take care and do not worry. You will be fine.

Above answer was peer-reviewed by : Dr. Yogesh D