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Name of the Patient : Abc Xyzn lmn / M / 27 yrs.
Referred by : Dr. Abc Xyzmpat.
Examination : M.R.I. of the Brain.

CLINICAL PROFILE :

Patient handicapped since birth.
H/O seizures since childhood with left sided weakness. On anti-epileptics.
C/O backache since 1 year for which patient was given an injection. Since then C/O paresthesias in the RLE.

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.

3 mm thick T2 Weighted coronal images.

OBSERVATION :

There are well marginated CSF intensity lesions on all the pulse sequences in the lentiform nuclei, posterior capsular regions and corona radiata bilaterally and in the left thalamus. These lesions represent areas of cystic encephalomalacia, most likely the sequelae of a previous vascular insult. Resultant mild dilatation of the bodies of the lateral ventricles is noted.

The right cerebral peduncle appears slightly smaller in size as compared to left.

The hippocampal complex is unremarkable on either side.

The third and the fourth ventricles are normal. The basal cisternal spaces are unremarkable. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.



Incidentally noted is a polyp in the right maxillary antrum.

IMPRESSION :

1. Areas of cystic encephalomalacia in the lentiform nuclei, posterior capsular regions and corona radiata bilaterally and in the left thalamus most likely is the sequelae of previous vascular insult.

2. Small right cerebral peduncle may be due to Wallerian degeneration.




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