ke/hs/rg/nl
/00007 Date : 00.00.00

Name of the Patient : Abc Xyz Plmn / M / 30 yrs.
Referred by : Dr. Abc Xyztel.
Examination : M.R.I. of the Brain.

CLINICAL PROFILE :

C/O giddiness, vomiting and inability to walk since 5-6 days and tendency to fall to the right side.

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.

OBSERVATION :

There are hyperintense areas in the right cerebellar hemisphere inferiorly and posterior to the fourth ventricle on the proton, T2 Weighted and Fast Scan (T2 *) images. These are hypointense to grey matter on the T1 Weighted images. Similar areas are noted in the medulla on the right side, posteriorly. There is mild compression upon the fourth ventricle. There is herniation of the cerebellar tonsils through the foramen magnum.

There is mild fullness of both the lateral ventricles. The third ventricle is re normal. The basal cisternal spaces are unremarkable. There is no shift of the midline structures.

The calibre of the right vertebral artery is smaller as compared to the opposite side.

Incidental note is made of left frontal sinusitis.

IMPRESSION :

Altered signal in the right cerebellar hemisphere and medulla as described on the right side, would represent a fresh infarct (right posterior inferior cerebellar artery territory and the watershed with the right superior cerebellar artery).