Date : 00.00.00
Name of the Patient : Abc Xyz Gailmn / M / 47 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
C/O slowiness of movement with difficulty in walking since 1 1/2 years.
Also C/O involuntary movements of the fingers of the right hand since 00.00.00 which has recovered now.
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 and Fast Scan (T2 *) coronal images.
5 mm thick T1 Weighted sagittal images.
There is an ill-defined, hyperintense lesion on the proton, T2 Weighted and FLAIR images in the right cerebellar hemisphere. This lesion appears hypointense on the T1 Weighted images and most likely represents an ischemic lesion. Indentation on the posterior fourth ventricle on the right side is noted.
Lacunar infarcts are seen in the pons, lentiform nuclei bilaterally, right thalamus and in the corona radiata and centrum semiovale bilaterally.
Ill-defined hyperintense areas on the proton, T2 Weighted and FLAIR images in the periventricular white matter bilaterally most likely represents ischemic changes.
There is mild dilatation of both the lateral and the third ventricles. The fourth ventricle is normal. There is prominence of the cerebral cortical sulci and the basal cisternal spaces bilaterally. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.
No obvious haemorrhage is detected on this study. Inflammatory changes are noted in the maxillary sinuses bilaterally.
1. Altered signal in the right cerebellar hemisphere most likely represents an ischemic lesion, probably recent.
2. Lacunar infarcts in the pons, lentiform nuclei bilaterally, right thalamus and in the corona radiata and centrum semiovale bilaterally.
3. Periventricular white matter ischemic changes bilaterally.
4. Mild cerebral cortical atrophy.