Date : 00.00.00
Name of the Patient : Abc Xyz. Mustlmn / F / 24 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
H/O left mastoidectomy with drainage of abscess done on 00.00.00
C/O involuntary movements of the LUE and LLE, gait ataxia, speech disturbances and deviation of the eyes to the left side since February 0000.
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.
3 mm thick T1 Weighted coronal images.
MR Cisternogram was obtained in the coronal plane.
There is slight prominence of the cerebellar folia on the left, inferiorly and posteriorly. An area which is isointense to CSF on all the pulse sequences is seen in the left cerebellar hemisphere. Ill-defined, hyperintense signal, best appreciated on the FLAIR images is noted in the left cerebellar hemisphere in the region of the prominent cerebellar folia. These changes may be the sequelae of previous surgery and would represent areas of encephalomalacia.
There is seen an approximately 1.2 cms diameter sized well-defined, intermediate signal intensity lesion on the T1 Weighted images in the left middle ear cavity, which appears hyperintense on the T2 Weighted images (scans 104.7, 108.7, 109.8).
A lacunar infarct (iso to hyperintense to CSF) is noted in the right thalamus/right parathird ventricular region.
There is mild dilatation of the both the lateral, third and the fourth ventricles. There is a hypointense signal, more pronounced on the proton and T2 Weighted images in the third ventricle, aqueduct and the fourth ventricle. This suggests turbulent CSF flow.
The basal cisternal spaces are unremarkable. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.
1. Post-operative status with the changes in the left cerebellar hemisphere, described above being the sequelae of previous surgery (areas of encephalomalacia).
2. Mild communicating hydrocephalus.
3. A lacunar infarct in the right thalamus/parathird ventricular region.
4. An approximately 1.2 cms diameter sized lesion in the left middle ear cavity is not specific for a single etiology. A Choleasteatoma is a likely possibility.