sb/ke/nl/nl
Date : 00.00.00
Name of the Patient : Abc Xyzm Jaffer Walmn / M / 54 yrs.
Referred by : Dr. Abc Xyzmpat.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
C/O gait ataxia since 10 years.
Known hypertensive.
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 a small, hyperintense signal best appreciated on the FLAIR images in the subcortical white matter in the right fronto-temporal region and in the right inferior frontal region (scans 105.10, 16). These lesions appear nearly isointense to normal white matter on the T1 Weighted images.
There is prominence of the cerebellar folia bilaterally without change in signal intensity with mild dilatation of the fourth ventricle.
There is also mild dilatation of both the lateral ventricles. The third ventricle is normal. There is slight prominence of the cerebral cortical sulci and the basal cisternal spaces bilaterally. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.
Screening, T2 Weighted sagittal images of the cervical spine reveal small posterior disc herniations with peridiscal osteophytes over the C3-C4 to C6-C7 levels.
IMPRESSION :
1. Altered signal in the subcortical white matter in the right fronto-temporal region and in the right inferior frontal region most likely represent ischemic changes.
2. Mild to moderate cerebellar atrophy.