État criblé with acute on chronic ischemia and amyloid angiopathy
Dementia with previous left-sided weakness, now worsening. Imaging requested to investigate a possible recent infarction or hemorrhage.
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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 ischemia. 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 hemorrhage.
This patient has the full hand of degenerative vascular disease of the brain: widespread old deep (periventricular) ischemic change including lacunes (etat lacunaire), more acute deep infarction and widespread foci of hemosiderin (magnetic susceptibility) indicating sites of microhemorrhage 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).