Date : 00.00.00
Name of the Patient : Abc Xyzta Yenclmn / F / 22 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Dorsal Spine.
CLINICAL PROFILE :
C/O backache with paresthesias in BLE with associated weakness.
M.R.I of the dorsal spine was performed using the following parameters :
4 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and T2 Weighted axial images through the region of interest.
The brain was screened with 5 mm thick T2 Weighted axial images and the optic nerves were screened with 3 mm thick STIR coronal images.
There is evidence of a fairly well-defined area which is near isointense to CSF on all the pulse sequences within the cord at the D7 and D8 vertebral levels. This may represent an area of myelomalacia.
A few of the visualized dorsal intervertebral discs show loss of water content.
The visualized dorsal vertebral bodies and the pre and paravertebral soft tissues are unremarkable.
The conus medullaris terminates at the D12 level.
On screening the brain there is evidence of a hyperintense focus on the T2 Weighted images within the pons, centrally. Also seen is mild fullness of the fourth and both the lateral ventricles. There is slight prominence of the cerebellar folia and cerebral cortical sulci bilaterally.
The visualized optic nerves show normal signal intensity bilaterally on the STIR images.
The MRI features are suggestive of :
1. An area of altered signal intensity within the cord at the D7 and D8 vertebral levels most likely represents an area of myelomalacia.
2. An area of altered signal intensity within the pons is not specific for a single etiology (? demyelination, ?? ischemia).
3. Mild cerebral and cerebellar atrophy.
As compared to the previous MRI dated 00.00.00 (Study No.00001). the previously identified lesion in the cord has now become myelomalacic. On review of the previous films and correlating with the MRI brain findings, the diagnosis of a demyelinating/ischemic lesion should be considered.