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Date : 00.00.00

Name of the Patient : Abc Xyz Mohalmn / M / 70 yrs.
Referred by : Dr. Abc Xyzarucha.
Examination : M.R.I. of the Brain.

CLINICAL PROFILE :

C/O difficulty in getting up without support since 4-5 months.
Known hypertensive.

EXAMINATION :

M.R.I of the brain was performed using the following parameters :

5 mm thick T1 Weighted, proton and T2 Weighted axial images.

5 mm thick FLAIR coronal images.

OBSERVATION :

There is an ill-defined, hypointense signal on the T1 Weighted images in the right temporo-parieto-frontal lobes and in the right lentiform nucleus and head of the right caudate nucleus. This follows CSF signal on all the pulse sequences. Areas of hypointensity on the T1 Weighted images which turn hyperintense on the proton, T2 Weighted and FLAIR images adjacent to this would represent gliotic changes. This lesion in toto represents an area of cystic encephalomalacia, most likely the sequelae of a previous vascular insult. Resultant mild fullness of the right lateral ventricle is noted when compared to the left.

A lacunar infarct (iso to hyperintense to CSF) is noted in the pons on the right.

There is mild dilatation of both the lateral and third ventricles. The fourth ventricle is normal.

There is slight prominence of the cerebral cortical sulci, cerebellar folia and basal cisternal spaces bilaterally.

There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.
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IMPRESSION :

1. Altered signal in the right temporo-parieto-frontal lobes and in the right lentiform nucleus and head of right caudate nucleus represents an area of cystic encephalomalacia most likely the sequelae of a previous vascular insult.

2. A lacunar infarct in the pons to the right of the midline.

3. Mild age related cerebral cortical and cerebellar atrophy.

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