Differential Diagnosis

• Single most likely diagnosis:
  • Chronic small vessel ischemic disease: This is the most likely diagnosis given the presence of confluent and non-confluent hypodensities in the periventricular and subcortical white matter, which are consistent with chronic lacunar infarcts. The lack of evidence for acute hemorrhage or territorial infarcts further supports this diagnosis.
• Other Likely diagnoses:
  • Chronic lacunar infarcts: As mentioned, the focal hypodensities in the left centrum semiovale and pons could represent chronic lacunar infarcts, which are a common finding in small vessel disease.
  • Leukoaraiosis: The periventricular and subcortical white matter changes could also be consistent with leukoaraiosis, a condition characterized by diffuse white matter damage.
  • Normal pressure hydrocephalus (NPH): The mild prominence of the lateral ventricles and prominent cortical sulci could be suggestive of NPH, although this would require further evaluation.
• 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 not directly mentioned, the presence of vascular calcification in the cavernous segment of the bilateral ICA could be associated with a meningioma, which would require further imaging and evaluation.
• Rare diagnoses:
  • Multiple sclerosis: Although less likely, the white matter changes could be consistent with multiple sclerosis, particularly if the patient has a history of neurological symptoms.
  • Vasculitis: The presence of vascular calcification and white matter changes could be suggestive of a vasculitis, such as primary central nervous system vasculitis, although this would be a rare diagnosis.