sb/ke/rg/nl
Date : 00.00.00
Name of the Patient : Abc Xyzn lmn / F / 71 yrs.
Referred by : Dr. Abc Xyzftary.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
C/O mild giddiness with gait ataxia since 6-8 months.
Known hypertensive/diabetic. On Rx.
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 and Fast Scan (T2 *) coronal images.
4 mm thick STIR coronal images through the orbits.
OBSERVATION :
There is a CSF intensity lesion on all the pulse sequences in the
right parieto-occipital and posterior parietal region. Perilesional white matter hyperintense signal on the proton, T2 Weighted and FLAIR imagse is noted. Resultant mild dilatation of the atrium, posterior body and occipital horn of the right lateral ventricle is noted.
There is an ill-defined, hyperintense signal on the proton, T2 Weighted and FLAIR images in the posterior parietal periventricular white matter on the left and in the right frontal deep white matter. These changes appear iso to hypointense to normal white matter on the T1 Weighted images and most likely represents ischemic changes.
There is mild fullness of both the lateral ventricles. The third and the fourth ventricles are normal. The basal cisternal spaces are unremarkable. There is slight prominence of the cerebral cortical sulci and cerebellar folia bilaterally. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.
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The visualized optic nerves show normal signal intensity bilaterally.
IMPRESSION :
1. An area of cystic encephalomalacia with perilesional gliotic changes in the right parieto-occipital and posterior parietal region, ? the sequelae of a previous vascular insult.
2. Altered signal in the posterior parietal periventricular white matter on the left and in the right frontal deep white matter most likely represents ischemic changes.
3. Mild cerebral cortical and cerebellar atrophy.