Name of the Patient : Abc XyzPalmn / M / 62 yrs.
Referred by : Dr. Abc Xyzhta.
Examination : Intracranial and Neck M.R.A.
CLINICAL PROFILE :
C/O gait imbalance and giddiness since 00.00.00.
The brain was screened with 5 mm thick 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.
An encephalomalacic area is noted in the right cerebellar hemisphere, inferiorly, most likely the sequelae of previous ischemic lesion.
Hyperintense areas on the T2 Weighted and FLAIR images along the left frontal cortex, left frontal periventricular white matter and in the right frontal deep white matter, most likely represent ischemic lesions.
There is mild fullness of both the lateral and the third ventricles. The fourth ventricle is normal. There is slight prominence of the cerebral cortical sulci and the cerebellar folia bilaterally. There is no shift of the midline structures.
Incidentally noted is degenerative changes in the cervical spine.
INTRACRANIAL MRA :
There is ectasia of the vertebro-basilar system.
There is slight irregularity of the distal cavernous and supraclinoid segments of the left internal carotid artery and the distal segment of the right middle cerebral artery.
- 2 - Scan-00007/60
The petrous segment of the internal carotid arteries bilaterally and the cavernous and supraclinoid segments of the right internal carotid artery show normal signal and calibre. The visualized anterior cerebral, left middle cerebral, basilar, vertebral and posterior cerebral arteries also show normal signal, calibre and wall margins. No obvious aneurysm or vascular malformation is identified.
NECK MRA :
There is significant narrowing of the left external carotid artery and its origin. The left common carotid artery and the left internal carotid artery in the neck, the right common carotid artery and its bifurcation and the vertebral arteries are unremarkable.
1. An encephalomalacic area in the right cerebellar hemisphere, inferiorly, the sequelae of previous vascular insult.
2. Altered signal along the left frontal cortex, left frontal periventricular white matter and in the right frontal deep white matter, most likely represent ischemic lesions.
3. Irregularity of the distal cavernous and supraclinoid segments of the left internal carotid artery and the distal segment of the right middle cerebral artery with significant stenosis of the left external carotid artery at its origin is most likely atherosclerotic in etiology.