Multiple embolic infarctions

This patient is a 49 year old right handed woman with known metastatic adenocarcinoma of the lung, who presented to the Emergency Department with difficulty speaking. She had undergone chemotherapy and radiation therapy for her cancer 1 year previously, and was recently found to have liver metastases. A head CT done one month prior to admission as part of her oncology workup was negative for metastases. She described having the "words in mind" but could not get her "mouth to work properly". On admission, she was hypophonic and mildly dysarthric. Examination of language function revealed very slow, spontaneous verbal output, but she was able to string together 5 words into a sentence. She could repeat short phrases correctly, name high and low frequency objects, and read out loud. She had difficulty writing a simple sentence and had spelling errors. She had a mild right facial droop, but no right pronator drift or other motor signs. MR images revealed multiple bilateral foci of restricted diffusion, involving the cerebellar hemispheres, the occipital and parietal lobes, and the left frontal lobe. The best views of these lesions are with FLAIR images, in which they are seen as faint foci of T2 prolongation. MRA and MRV were negative. These image fidings likely represent multiple embolic infarcts.
Some details have been altered to protect confidentiality.
Keith A. Johnson, J. Alex Becker