Date : 00.00.00
Name of the Patient : Abc Xyz lmn / F / 62 yrs.
Referred by : Dr. Abc Xyzl.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Known C/O potts spine detected in October 0000. On Rx since September 0000.
C/O weakness of BUE and BLE with bladder/bowel involvement.
H/O V.P. shunt done in January and February 0000.
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 seen moderate dilatation of both the lateral, third and the fourth ventricles. There are ill-defined hyperintense areas on the proton, T2 Weighted and FLAIR images in the periventricular white matter bilaterally which represents periventricular CSF ooze, in the given clinical setting. A shunt tube is seen to traverse the right lateral ventricle with its tip extending slightly beyond the body of the right lateral ventricle. A hypointense signal, more pronounced on the proton and T2 Weighted images is noted in the posterior third ventricle, aqueduct and the proximal fourth ventricle which may suggest increased CSF flow. The sulcal spaces are effaced bilaterally.
Small bright foci on the proton, T2 Weighted and FLAIR images are noted in the subcortical white matter in the fronto-parietal regions bilaterally.
The prepontine and paramedullary cisterns are prominent. A mega cisterna magna is noted.
There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.
C1-C2 anomaly is noted (? old fracture, ?? occipitalized atlas).
1. Post-shunt status with a shunt tube traversing the right lateral ventricle.
2. Moderate communicating hydrocephalus with periventricular CSF ooze and sulcal space effacement.
As compared to the previous MRI dated 00.00.00, there is no significant change in the size of the ventricles.