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sb/ke/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyz Kaplmn / M / 67 yrs.
Referred by : Dr. Abc Xyzmpat.
Examination : M.R.I. of the Brain.

CLINICAL PROFILE :

C/O multiple CVA since 0000.
Known hypertensive.

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.

5 mm thick T1 Weighted sagittal images.

OBSERVATION :

There are ill-defined, hyperintense areas on the proton, T2 Weighted and FLAIR images in the pons and the periventricular white matter, corona radiata and centrum semiovale bilaterally. These lesions appear hypointense to normal white matter on the T1 Weighted images and most likely represent ischemic changes.

A CSF signal intensity lesion on all the pulse sequences in the right high frontal region may represent an area of cystic encephalomalacia, most likely a sequelae of previous vascular insult (scans 104.16, 17, 105.13, 14).

Lacunar infarcts are noted in the pons, thalami and lentiform nuclei bilaterally and in the corona radiata and centrum semiovale bilaterally.

There is mild dilatation of both the lateral, third and fourth ventricles. There is prominence of the cerebral cortical sulci, cerebellar folia and basal cisternal spaces bilaterally.


There is no shift of the midline structures.

The midbrain and the pons appear slight decreased in bulk as compared to normal.

IMPRESSION :

1. Areas of altered signal in the pons and the periventricular white matter, corona radiata and centrum semiovale bilaterally most likely represent ischemic changes.

2. An area of cystic encephalomalacia in the right high frontal region is most likely the sequelae of previous vascular insult.

3. Lacunar infarcts in the pons, thalami and lentiform nuclei bilaterally and in the corona radiata and centrum semiovale bilaterally.

4. Cerebral cortical and cerebellar atrophy.

As compared to the previous MRI (study no.00002) dated 00.00.00,
there is no significant change noted.

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