Date : 00.00.00
Name of the Patient : Abc XyzJailmn / F / 16 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
C/O multiple sclerosis detected in October 0000. Recovered with Rx.
Now C/O neck pain with paresthesias in BUE and BLE since 2 months.
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.
The cervical and dorsal spines were screened with 4 mm thick T2 Weighted sagittal images.
There is still seen a well marginated, hyperintense lesion on the proton, T2 Weighted and FLAIR images in the left centrum semiovale, in close relation to the wall of the body of the left lateral ventricle. This lesion appears iso to hypointense to normal white matter on the T1 Weighted images (scans 105.11, 102.14, 103.14). Similar lesions are noted along the lateral margin of the temporal horn of the right lateral ventricle (scan nos. 102.7 & 105.12) and along the right high frontal cortex (scan no. 102.15). The later two lesions are also identified on the previous study, dated 00.00.00.
There is mild fullness 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.
Inflammatory changes are seen in the sphenoid and maxillary sinuses.
Screening images of the cervical and dorsal spines reveal a minimally swollen cervical cord with an ill-defined hyperintense signal within the cervical cord, centrally extending over the C2 and C3 vertebral levels. The T2 Weighted sagittal images of the dorsal spine show a focal hyperintensity within the cord at the D11-D12 level.
IMPRESSION :Altered signal in the left centrum semiovale, right temporal region, right high frontal cortex and in the cervical and dorsal spinal cords at the C2, C3 and D1-D2 levels as described most likely represents demyelinating lesions in the given clinical setting.As compared to the previous MRI dated 00.00.00, (study no.0000), there is slight reduction in the size of the lesion in the left centrum semiovale. The lesion in the right temporal and right high frontal region were also identified on the previous study and are largely unchanged. There is significant reduction in the lesion in the cervical and dorsal cords. The lesion in the dorsal cord at the D5/D6 level is not well-identified on this study.