Date : 00.00.00
Name of the Patient : Abc Xyz Panlmn / F / 43 yrs.
Referred by : Dr. Abc Xyztrak.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
H/O subtotal excision of pituitary adenoma in 0000.
C/O headaches since 3 years.
M.R.I of the brain, sella and perisellar region was performed using the following parameters :
5 mm thick T1 Weighted and T2 Weighted axial images.
5 mm thick FLAIR coronal images.
3 mm thick T1 Weighted and T2 Weighted coronal images through the sella and perisellar region.
3 mm thick T1 Weighted sagittal images through the sella and perisellar region.
There is evidence of a right frontal craniotomy. Slight volume loss is noted in the right frontal lobe with an ill-defined, hyperintense signal on the T2 Weighted and FLAIR images in the right inferior frontal region, most likely the sequelae of previous surgery.
There is still seen a well marginated, approximately 1.0 x 1.8 x 1.3 cms sized mass lesion in the suprasellar cistern, superior to the intracranial segment of the right optic nerve. This lesion is nearly isointense to the parenchyma on all the pulse sequences (scans 104.8, 102.8, 107.6, 103.6 & 7, 106.7). Minimal inferior displacement of the proximal right optic nerve is noted.
The sella is slightly widened. The pituitary gland shows a normal concave margin. The pituitary stalk is deviated to the left. The cavernous sinuses are unremarkable on either side.
Both the lateral, third and the fourth ventricles are normal. No obvious vascular anomaly is identified on this study.
There is thickening of the skull vault in the left frontal region.
Inflammatory changes are noted in the left maxillary antrum.
1. Post-operative changes with encephalomalacic changes in the right frontal lobe.
2. An approximately 1.0 x 1.8 x 1.3 cms sized mass lesion in the suprasellar cistern, superior to the intracranial segment of the right optic nerve as described, most likely represents the residual pituitary macroadenoma, in the given clinical setting. (No pre-operative scans were available for comparison).
As compared to the previous CT-Scan dated 00.00.00, there is no significant change in the size of the lesion.