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hs/ke/rg/nl
Date : 00.00.00

Name of the Patient : Abc XyzD. Hlmn / M / 22 yrs.
Referred by : Dr. Abc Xyzshar.
Examination : M.R.I. of the Brain.

CLINICAL PROFILE :

C/O change in voice.
H/O Pulmonary kochs 1 year ago. Received AKT for 8 months.

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 is evidence of a hyperintense signal on the proton and T2 Weighted images within the tectum. The tectum is seen to be bulky with resultant compression of the aqueduct. There is resultant mild to moderate dilatation of the third and both the lateral ventricles.

An extramedullary mass lesion is noted within the spinal canal on the right side at the C2 and C3 vertebral levels. It is seen to compress and displace the cord to the left side (The cord shows a suspicious hyperintense signal on the T2 Weighted images at these levels and this may represent cord edema/ischemia). This lesion is hypointense on the T1 Weighted images and turns hyperintense on the T2 Weighted images. This lesion is seen to extend into the right paravertebral soft tissues via the right C2-C3 neural foramen, which is enlarged.

The fourth ventricle is normal. 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. A bulky tectum with altered signal may represent a glial cell tumor or hamartoma.

2. Mild to moderate obstructive hydrocephalus.

3. An extramedullary lesion within the spinal canal on the right side at the C2 and C3 vertebral levels with extensions as described most likely represents a neurofibroma.

The above findings may be seen with neurofibromatosis and a contrast enhanced study may be worthwhile.
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