sb/ke/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyzi Pulmn / F / 69 yrs.
Referred by : Dr. Abc Xyzemmady / Dr. Abc Xyzdar.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
Past H/O aspiration of left convexity subdural hematoma on 00.00.00.
H/O sudden onset of weakness all over the body and dysarthria for 2-3 hours, 2 days back which is recovered. No complaints at present.
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 an ill-defined, hyperintense signal on the proton, T2 Weighted and FLAIR images in the pons on the right, medially. This lesion appears iso to hypointense to normal white matter on the T1 Weighted images and most likely represents an ischemic lesion, probably recent in the given clinical setting.
There are ill-defined, hyperintense areas on the proton, T2 Weighted and FLAIR images in the periventricular white matter bilaterally and in the subcortical white matter in the frontal regions bilaterally. These lesions also appear iso to hypointense to normal white matter on the T1 Weighted images and represent ischemic changes.
Lacunes are noted in the lentiform nuclei and left corona radiata.
There is mild to moderate dilatation of both the lateral and the third ventricles and mild dilatation of the fourth ventricle. There is prominence of the cerebral cortical sulci, cerebellar folia and the basal cisternal spaces bilaterally. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.
Incidentally noted is an empty sella and a burr hole in the left temporal region.
IMPRESSION :
1. Altered signal in the pons on the right, medially
most likely represents an ischemic lesion, probably recent in the given clinical setting.
2. Altered signal in the periventricular white matter bilaterally and in the subcortical white matter in the frontal regions bilaterally represent ischemic changes.
3. Lacunes in the lentiform nuclei and left corona radiata.
4. Patient is status post-burr hole aspiration of the left sided convexity, subdural, hematoma.
As compared to the previous CT Scan dated 00.00.0000, there is no significant change in the size of the ventricles.
The pontine lesion seen on the present study was not visualized on the previous MRI dated 00.00.00.