sb/ke/nl/rg.
Date : 00.00.00

Name of the Patient : Abc XyzPlmn / M / 15 yrs.
Referred by : Dr. Abc Xyztel.
Examination : M.R.I. of the Brain.

CLINICAL PROFILE :

C/O headaches, numbness on the right side of face, giddiness, gait ataxia and diplopia since 3 weeks.
Known C/O RHD with mental retardation and AAD with T.P. Shunt.
Posterior fixation with excision of odontoid process with T. P. shunt done 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.

3 mm thick T1 Weighted and STIR coronal images.

5 mm thick T1 Weighted sagittal images.

OBSERVATION :

Susceptibility artifacts are noted in the region of the posterior fossa and upper cervical spine. It is hence, difficult to evaluate the status of the posterior fossa and the atlanto-axial region including the upper cervical spinal cord.

There is a small bright foci on the proton and T2 Weighted images in the left posterior parietal deep white matter. This lesion appears hypointense to normal white matter on the T1 Weighted images. Prominent perivascular space is noted in the right frontal deep white matter.

There is mild fullness of both the lateral ventricles. The third ventricle is unremarkable.



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

The optic nerves on either side show normal signal.

IMPRESSION :

1. Susceptibility artifacts in the region of the posterior fossa and upper cervical spine. It is hence, difficult to evaluate the status of the posterior fossa and the atlanto-axial region including the upper cervical spinal cord.

2. Small bright foci on the proton and T2 Weighted images in the left posterior parietal deep white matter is not specific for a single etiology ? vascular insult.