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ke/hs/nl/nl
Date : 00.00.00

Name of the Patient : Abc XyzPolmn / F / 70 yrs.
Referred by : Dr. Abc Xyzmpat.
Examination : M.R.I. of the Brain.

CLINICAL PROFILE :

C/O headaches, gait ataxia and drooping of the left eyelid since 2 days.
H/O fever since 10 days.
Known hypertensive.
H/O weakness of the RUE with altered speech 2 1/2 years back (has recovered).

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 are hypointense areas in the right temporo-occipital and the right high parietal region on the T1 Weighted images which are seen to turn heterogeneously hyperintense on the proton, T2 Weighted and FLAIR images. Few areas which are isointense to CSF are also noted in these lesions and would represent cystic changes. Sulcal spaces are prominent in this region.

A small hyperintense focus seen in the midbrain posteriorly, better appreciated on the FLAIR images (se/im 105.9).










There is mild fullness of the ventricular system. There is prominence of the cerebral cortical sulci and cerebellar folia bilaterally.

The basal cisternal spaces are unremarkable. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.

IMPRESSION :

1. Areas of encephalomalacia in the right temporo-occipital and the right high parietal region.

2. A focus of altered signal intensity in the midbrain posteriorly, is most likely ischemic in etiology.

3. Age related cerebral and cerebellar atrophy.


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