État criblé with acute on chronic ischaemia and amyloid angiopathy
Dementia with previous left-sided weakness, now worsening. Imaging requested to investigate a possible recent infarction or haemorrhage.
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Widespread periventricular T2 brightening - FLAIR sequence separates into fluid (low signal) in old lacunes and etat criblé, and gliosis in areas of ischaemia. Note restricted diffusion and reduced ADC in the right corona radiata and posterior limb of internal capsule = acute infarction. Widespread foci of magnetic susceptibility throughout the brain probably represent sites of old haemorrhage.
This patient has the full hand of degenerative vascular disease of the brain: widespread old deep (periventricular) ischaemic change including lacunes (etat lacunaire), more acute deep infarction and widespread foci of haemosiderin (magnetic susceptibility) indicating sites of microhaemorrhage including the brain stem. The brain is atrophic resulting in marked dilatation of the perivascular (Virchow-Robin) spaces causing the appearance of etat criblé (sieve-like state).