sb/ke/nl/nl
Date : 00.00.00
Name of the Patient : Abc XyzPlmn / M / 45 yrs.
Referred by : Dr. Abc Xyz. Tandel.
Examination : Intracranial and Neck M.R.A.
CLINICAL PROFILE :
Alleged H/O road traffic accident on 00.00.00 with left hemiparesis, slurred speech and memory impairment since December 0000.
EXAMINATION :
The brain was screened with 5 mm thick T2 Weighted axial images and 5 mm thick Fast Scan (T2 *) coronal images.
Intracranial and neck MRA were performed with 3D TOF and 2D TOF sequences, respectively.
OBSERVATION :
There is a hypointense signal on the T2 Weighted images, but more pronounced on the Fast Scan (T2 *) images in the right thalamus, extending into the right corona radiata. This lesion represents residual hemosiderin, the sequelae of previous bleed. Perilesional hyperintense signal may represent gliotic changes.
There is mild dilatation of the ventricular system. The basal cisternal spaces are unremarkable. There is slight prominence of the cerebral cortical sulci and cerebellar folia bilaterally. There is no shift of the midline structures.
Incidentally noted is right maxillary sinusitis.
Atlanto-dens subluxation is also noted.
INTRACRANIAL MRA :
The petrous, cavernous and supraclinoid segments of the internal carotid arteries bilaterally show normal signal and calibre. The visualized anterior cerebral, 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 :
The common carotid arteries and their extracranial branches appear normal bilaterally. There are no vessel wall irregularities or stenosis of the vessels noted.
IMPRESSION :
1. Residual hemosiderin in the right thalamus extending into the right corona radiata.
2. Mild communicating hydrocephalus.
3. Atlanto-dens subluxation.
4. No significant abnormality is detected on the intracranial and neck MRA on this study.