sb/hs
Date : 00.00.00

Name of the Patient : Abc Xyz Shlmn / M / 50 yrs.
Referred by : Dr. Abc Xyzs.
Examination : Intracranial and Neck M.R.A.

CLINICAL PROFILE :

C/O gait imbalance with inability to concentrate and recognize objects on the right side.

EXAMINATION :

The brain was screened with 5 mm thick T2 Weighted axial images.

Intracranial and neck MRA were performed with 3D TOF and 2D TOF sequences, respectively.

OBSERVATION :

There is an ill-defined, hyperintense area on the T2 Weighted images in the left parieto-occipital lobe. This lesion appears hypointense on the T1 Weighted images and represents an area of cystic encephalomalacia, most likely the sequelae of a previous vascular insult. Resultant mild dilatation of the atrium and occipital horn of the left lateral ventricle is noted.

Ill-defined, hyperintense areas on the T2 Weighted images are noted in the periventricular white matter bilaterally and in the corona radiata, centrum semiovale and subcortical white matter in the fronto-parietal regions bilaterally. These also most likely represent ischemic changes.

A lacunar infarct is noted in the right periatrial region.

There is mild dilatation of both the lateral and third ventricles. The fourth ventricle is normal. There is slight prominence of the cerebral cortical sulci and cerebellar folia bilaterally. There is no midline shift.
Scan - 00002


An antro-choanal polyp is noted on the right side. A polyp is also noted in the left maxillary antrum.

Incidentally noted is an empty sella.

The basal cisternal spaces are unremarkable.

INTRACRANIAL MRA :

The right vertebral artery appears hypoplastic. The posterior cerebral arteries are slightly attenuated, bilaterally.

The petrous, cavernous and supraclinoid segments of the internal carotid arteries bilaterally show normal signal and calibre. The visualized anterior cerebral, middle cerebral, basilar, left vertebral arteries also show normal signal, calibre and wall margins. No obvious aneurysm or vascular malformation is identified.

NECK MRA :

The common carotid arteries and its bifurcation and branches bilaterally are unremarkable.

IMPRESSION :

1. An area of cystic encephalomalacia in the left parieto- occipital region, the sequelae of previous vascular insult.

2. Altered signal in the periventricular white matter and in the corona radiata, centrum semiovale and in the subcortical white matter in the fronto-parietal regions bilaterally, most likely represents ischemic changes.

3. Hypoplastic right vertebral artery with attenuated posterior cerebral arteries bilaterally.

4. Right sided antro-choanal polyp.