Date : 00.00.00
Name of the Patient : Abc Xyzn Shlmn / M / 85 yrs.
Referred by : Dr. Abc Xyzmpat / Dr. Abc Xyzporia.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
C/O seizures on 00.00.00 with altered sensorium since then.
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 a CSF intensity lesion on all the pulse sequences in the left cerebellar hemisphere, inferiorly. This lesion represents an area of cystic encephalomalacia, most likely the sequelae of a previous vascular insult. Perilesional hyperintense signal on the T2 Weighted and FLAIR images may represent gliotic changes.
There are small bright foci on the proton, T2 Weighted and FLAIR images in the posterior parietal periventricular white matter bilaterally and in the right centrum semiovale. These lesions appear isointense to normal white matter on the T1 Weighted images and most likely represent ischemic changes.
There is mild dilatation of both the lateral and third ventricles. The fourth ventricle is normal. There is prominence of the cerebral cortical sulci, left cerebellar folia and the basal cisternal spaces bilaterally. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.
The right eye is aphakic.
1. An area of cystic encephalomalacia in the left cerebellar hemisphere, inferiorly, most likely the sequelae of a previous vascular insult.
2. Altered signal in the posterior parietal periventricular white matter bilaterally and in the right centrum semiovale most likely represent ischemic changes.
3. Mild cerebral and cerebellar atrophy.