hs/sb/nl/nl
Date : 00.00.00

Name of the Patient : Abc Xyz Salmn / F / 13 yrs.
Referred by : Dr. Abc Xyzwant.
Examination : M.R.I. of the Brain and Spine.

CLINICAL PROFILE :

C/O fever since 2 1/2 months.
C/O headaches and seizures 1 1/2 months back.
H/O Pulmonary kochs since 00.00.00. On AKT since then.
H/O VP shunt 18 days back.

EXAMINATION :

The brain was scanned as requested using 5 mm thick T2 Weighted axial images.

The cervico-dorsal spine was scanned as requested using 4 mm thick T1 Weighted and T2 Weighted sagittal images.

The dorso-lumbar spine was scanned as requested using 5 mm thick T1 Weighted and T2 Weighted sagittal images and 5 mm thick T2 Weighted axial images.

OBSERVATION :

BRAIN :

There is a focal hyperintensity on the T2 Weighted images within the right cerebral peduncle.

Areas of hyperintensity are noted within the left lentiform nucleus and the white matter adjacent to the left frontal horn.

There is mild fullness of the ventricular system.

A ventriculostomy shunt tube is seen to course through the right parietal lobe with the tip of the tube lying within the right frontal horn.



There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.

Hypointense areas with susceptibility artifacts and fluid level on all the pulse sequences are seen within the frontal horns of both the lateral ventricles and these would represent air.

SPINE :

A small postero-central disc herniation is seen to indent the thecal sac at the L1-L2 level.

The L1-L2, L2-L3 and L3-L4 intervertebral discs show loss of water content.

The rest of the cervico-dorso-lumbar intervertebral discs show normal signal intensity.

The cervico-dorso-lumbar vertebral bodies show normal signal intensity.

The visualized pre and paravertebral soft tissues are unremarkable.

The conus medullaris terminates at the L1 level and the thecal sac terminates at the S1 level.

IMPRESSION :

1. Post-shunt status.

2. Mild fullness of the ventricular system.
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3. Areas of altered signal within the right cerebral peduncle, the left lentiform nucleus and the white matter adjacent to the left frontal horn may represent ischemic changes.

4. A small postero-central disc herniation at the L1-L2 level.

5. Air within the frontal horns of both the lateral ventricles.