Date : 00.00.00
Name of the Patient : Abc Xyz. Gholmn / M / 15 yrs.
Referred by : Dr. Abc Xyzgy (Dr. Abc Xyzah).
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
C/O paresthesias on the right side of the body since 00.00.00, with slurred speech.
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.
There is a wedge shaped, hyperintense signal on the proton, T2 Weighted and FLAIR images in the pons on the left, which appears mildly hypointense to normal white matter on the T1 Weighted images. A focal hyperintensity on the proton, T2 Weighted and FLAIR images is seen in the left cerebral peduncle.
Lacunar infarcts (iso to hyperintense to CSF on all the pulse sequences) are noted in the right thalamus and in the splenium of the corpus callosum on the left.
An area of cystic encephalomalacia (isointense to CSF on all the pulse sequences is noted in the right cerebellar hemisphere antero-superiorly.
There is mild dilatation of both the lateral ventricles. The third and the fourth ventricles are normal. The basal cisternal spaces are unremarkable. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.
- 2 - Scan - 00007
1. Altered signal in the pons on the left is most likely an ischemic lesion, probably of recent onset.
2. Lacunar infarcts in the right thalamus and in the splenium of the corpus callosum on the left.
3. An area of cystic encephalomalacia in the right cerebellar hemisphere antero-superiorly is most likely the sequelae of a previous vascular insult.