Differential Diagnosis
- Single most likely diagnosis
- Small vessel disease (chronic lacunar infarcts): The presence of confluent and non-confluent hypodensities in the periventricular and subcortical white matter, along with focal hypodensity in the left centrum semiovale and pons, suggests chronic lacunar infarcts, which are characteristic of small vessel disease.
- Other Likely diagnoses
- Chronic microvascular ischemic changes: The pattern of hypodensities is also consistent with chronic microvascular ischemic changes, which can occur in the setting of hypertension, diabetes, or other vascular risk factors.
- Leukoaraiosis: The periventricular and subcortical white matter changes could also represent leukoaraiosis, a condition characterized by diffuse white matter damage, often associated with aging and vascular risk factors.
- Sinusitis: The mucosal thickening in the right sphenoid and maxillary sinuses suggests sinusitis, which could be contributing to the patient's symptoms.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
- Lymphoma: The 9.3 mm isodensity in the subcutaneous soft tissue of the right suboccipital region could represent lymphoma, which would require prompt evaluation and treatment.
- Meningioma: Although less likely, the isodensity could also represent a meningioma, which would require further evaluation and potential surgical intervention.
- Subarachnoid hemorrhage (SAH): Although the initial report mentions no evidence of acute hemorrhage, SAH can be subtle and require repeat imaging or lumbar puncture for diagnosis.
- Rare diagnoses
- Multiple sclerosis: The white matter changes could, in rare cases, represent multiple sclerosis, although the pattern and distribution would be atypical.
- Vasculitis: The vascular calcification in the cavernous segment of the bilateral ICA could suggest vasculitis, although this would be a rare and unlikely diagnosis without other supporting clinical features.
- Mitochondrial disorders: The combination of white matter changes and vascular calcification could, in rare cases, suggest a mitochondrial disorder, such as MELAS syndrome.