sb/hs/rg.
Date: 00.00.00
Name of the Patient : Abc Xyzlal Ralmn / M / 60 yrs.
Referred by : Dr. Abc Xyznamiya.
Examination : Intracranial and Neck M.R.A.
CLINICAL PROFILE :
C/O headaches and gait ataxia since 00.00.00.
EXAMINATION :
The brain was screened with 5 mm thick T1 Weighted and T2 Weighted axial images and 5 mm thick FLAIR coronal images.
Intracranial and neck MRA were performed with 3D TOF and 2D TOF sequences, respectively.
OBSERVATION :
There is a small hyperintense focus on the T2 Weighted and FLAIR images in the left lateral medulla. This lesion appears nearly isointense on the T1 Weighted images and most likely represents an ischemic lesion.
There is mild fullness of both the lateral and the third ventricles. The fourth ventricle is normal. There is prominence of the cerebral cortical sulci and cerebellar folia bilaterally.
The basal cisternal spaces are unremarkable. There is no shift of the midline structures.
The cervico-medullary junction appears normal.
Inflammatory changes are noted in the right posterior ethmoidal air cells.
INTRACRANIAL MRA :
The vertebro-basilar system appears ectatic. The right vertebral and the A1 segment of the right anterior cerebral artery appear hypoplastic. A kink of petrous segment of the left internal carotid artery is noted.
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There is slight narrowing of the distal cavernous segment and proximal supraclinoid segment of the right internal carotid artery.
The visualized left anterior cerebral, middle cerebral, basilar, left vertebral and posterior cerebral arteries also show normal signal, calibre and wall margins. No obvious aneurysm or vascular malformation is identified.
NECK MRA :
The right vertebral artery in the neck also appears hypoplastic.
A filling defect along the posterior wall of the proximal left internal carotid artery most likely is an atherosclerotic plaque. There is resultant mild narrowing of the proximal 1.0 cms of the left internal carotid artery.
The common carotid arteries, right internal and external carotid arteries, left external carotid artery and the left vertebral artery appear normal.
IMPRESSION :
1. Altered signal in the left lateral medulla most likely represents an ischemic lesion.
2. Ectasia of the vertebro-basilar system with hypoplastic right vertebral and the A1 segment of the right anterior cerebral artery.
3. A filling defect along the posterior wall of the proximal left internal carotid artery most likely is an atherosclerotic plaque.
4. Slight narrowing of the distal cavernous segment and proximal supraclinoid segment of the right internal carotid artery.