hs/bv/rg/nl
Date : 00.00.00

Name of the Patient : Abc Xyz lmn / M / 25 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Brain.

CLINICAL PROFILE :

C/O shivering of both hands, gait imbalance and change in hand-writing since 2 years.
H/O being operated for pus discharge from the right ear in 0000.

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.
5 mm thick T1 Weighted sagittal images.

OBSERVATION :

There is no focal area of altered signal intensity within the brain parenchyma.

There is prominence of the cerebellar folia bilaterally and mild fullness of the fourth ventricle.

The left lateral ventricle is slightly larger as compared to the right lateral ventricle and this may be a normal variant.

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

Post surgical/inflammatory changes are seen within the middle ear and mastoid air cells on the right side.

IMPRESSION :

The MRI features are suggestive of mild cerebellar atrophy.