sb/bv/rg/nl
Date : 00.00.00
Name of the Patient : Abc XyzA. Dulmn / F / 19 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
H/O tingling in the RUE (for 15 days) with loss of vision on the left side 1 1/2 months back which recovered.
Now C/O tingling in the LUE with diminished vision on the left side.
EXAMINATION :
M.R.I of the cervical spine was performed using the following parameters :
4 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and Fast Scan (T2 *) axial images.
OBSERVATION :
There is loss of water content of the cervical intervertebral discs.
There is a patchy ill-defined, hyperintense signal on the T2 Weighted and Fast Scan (T2 *) images within the cervical spinal cord, centrally and posteriorly at the C3-C4 disc level and the C5, D1 and D2 vertebral levels. These lesions appear nearly isointense to normal cord on the T1 Weighted images. Slight increase in the diameter of the cervical cord is noted over the C3 to C6 vertebral levels and at the D2 level.
Small posterior disc bulges are noted at the C3-C4, C4-C5 and C5-C6 levels.
The cervical vertebral bodies show normal signal intensity. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
There is no cord compression.
The atlanto-axial region and the cervico-medullary junction are unremarkable.
Lymphnodes are noted deep to the sternocleidomastoid muscles bilaterally.
Screening T2 Weighted sagittal images of the dorsal spine do not reveal any significant feature of note.
Inflammatory changes are noted in the sphenoid sinus.
IMPRESSION :
Patchy ill-defined signal within the cervical spinal cord, centrally and posteriorly at the C3-C4 disc level and the C5, D1 and D2 vertebral levels is not specific for a single etiology. These changes most likely represents demyelinating plaques in the given clinical setting.