Date : 00.00.00
Name of the Patient : Abc XyzRauf Shlmn / M / 21 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Cervical Spine.
CLINICAL PROFILE :
Known C/O TBM with hydrocephalus. On AKT.
C/O weakness of the RLE and RUE with diminished vision bilaterally, right more than left since 2 months.
M.R.I of the cervical spine was performed using the following parameters :
4 mm thick T1 Weighted and T2 Weighted sagittal images.
5 mm thick T1 Weighted and Fast Scan (T2 *) axial images.
There is loss of water content of the cervical intervertebral discs.
There is seen an approximately 1.9 x 0.9 x 2.3 cms sized, lobulated, intramedullary mass lesion within the cervical spinal cord at the C1/C2 level. This lesion is iso to slightly hypointense to the normal cord on the T1 Weighted images and appears hyperintense with a peripheral hypointense rim on the T2 Weighted images. There is resultant increase in the diameter of the of the cervical spinal cord at the site of the lesion with effacement of the surrounding CSF space at this level. Ill-defined hyperintense signal on the T2 Weighted images in the lower medulla and in the cervico-dorsal spinal cord over the C3 to D2 vertebral levels would represent perilesional edema.
Small postero-central protruded discs are noted at the C3-C4, C4-C5 and C5-C6 levels.
The cervical vertebral bodies show normal signal intensity. The joints of Luschka and the visualized pre and paravertebral soft tissues are unremarkable.
The atlanto-axial region is unremarkable.
Screening T2 Weighted axial images of the brain reveal mild dilatation of both the lateral, third and the fourth ventricles suggesting a communicating hydrocephalus. Minimal periventricular white matter hyperintense signal is noted on the T2 Weighted images. Compared to the previous CT Scan dated 19th August 0000, the ventricles appear slightly smaller in size.
Hyperintense signal in the medulla represents perilesional edema due to the intramedullary lesion at the C1/C2 level (described in the cervical spine study).
1. An approximately 1.9 x 0.9 x 2.3 cms sized, lobulated, intramedullary mass lesion within the cervical spinal cord at the C1/C2 level as described, most likely represent tuberculomas, in the given clinical setting. Perilesional edema is noted in the lower medulla and the cervico-dorsal spinal cord as described.
2. Mild communicating hydrocephalus.
A contrast enhanced scan would be worthwhile.