Multi-territory ischemic infarcts (pediatric)
Recurrent stroke-like symptoms occurring without any periodicity and spontaneously resolving without any significant focal neurological deficit.
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Axial T2 images showed diffuse gyral thickening in the left frontal lobe with volume loss noted in the right temporal lobe and small chronic infarct in deep white matter of the left posterior centrum semiovale. FLAIR images showed the gyral thickening to have increased signal intensity with small FLAIR patchy hyperintensities in the left high parietal region. DWI showed restriction along the gyral thickening with no significant restriction from the white matter in the left frontal lobe. ADC maps showed mild complementary changes to DWI images.
Post-contrast images show gyral enhancement in the left frontal lobe with multiple prominent enhancing vascular channels in bilateral gangliothalamic regions and along posterior pericallosal region.
Few prominent cortical vascular channels are also noted on left side.
Multi-territorial ischemic and gliotic changes, gyral thickening with restriction on DWI showing enhancement, multiple gangliothalamic vascular channels with patients clinical profile in view suggest a possible diagnosis of moyamoya disease/syndrome. Possible differential of MELAS can also be considered.