sb/ke/nl/nl
Date : 00.00.00
Name of the Patient : Abc Xyzm lmn / M / 65 yrs.
Referred by : Dr. Abc Xyzah.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
H/O fall 6 months back and 10-15 days back.
H/O altered sensorium since 6 months.
C/O gait ataxia since 1 1/2 months.
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 ill-defined, hyperintense areas on the proton, T2 Weighted and FLAIR images in the periventricular white matter bilaterally. These lesions appear isointense to normal white matter on the T1 Weighted images.
There is mild to moderate dilatation of both the lateral and third ventricles which is disproportionate to the degree of cerebral cortical atrophy. The fourth ventricle is also mildly dilated.
There is slight prominence of the cerebral cortical sulci, cerebellar folia and basal cisternal spaces.
There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.
Inflammatory changes are noted in the ethmoidal air cells bilaterally and in the left frontal sinus.
IMPRESSION :
1. Altered signal in the periventricular white matter bilaterally most likely represent ischemic changes.
2. Mild to moderate dilatation of both the lateral and third ventricles which is disproportionate to the degree of cerebral cortical atrophy. Normal pressure hydrocephalus should be ruled out.
3. Mild cerebral cortical and cerebellar atrophy.