KE/HS/RG.
Date : 00.00.00
Name of the Patient : Abc Xyzatlilmn / M / 71 yrs.
Referred by : Dr. Abc Xyzlkaka.
Examination : M.R.I. of the Brain.
CLINICAL PROFILE :
C/O gait ataxia since 1 year with memory impairment.
Alleged H/O fall 1 year ago.
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 hyperintense areas on the proton, T2 Weighted and FLAIR images in the periatrial white matter. These are iso to hypointense to the white matter on the T1 Weighted images. Similar smaller areas are noted in the white matter in the frontal lobes bilaterally.
There is fullness of both the lateral ventricles, and the third and fourth ventricles. There is prominence of the cerebral cortical sulci and cerebellar folia bilaterally. The basal cisternal spaces are unremarkable. There is no shift of the midline structures. No obvious vascular anomaly is identified on this study.
Incidental note is made of right maxillary sinusitis and an empty sella. Inflammatory changes are also seen in the ethmoidal air cells and sphenoid sinus.
- 2 - scan-00002
The cervical spine was screened with the help of T2 Weighted sagittal and Gradient axial images. Images show patient motion. Hyperintense area is seen within the cervical spinal cord at the C7 vertebral level which may represent cord edema/ischemia/gliosis.
Small posterior disc bulges with small peridiscal osteophytes are noted at the C3-C4, C4-C5, C5-C6 and the C6-C7 levels. The C4-C5, C5-C6 and C6-C7 facet joints on the left side show hypertrophic degenerative changes.
IMPRESSION :
1. Altered signal in the periatrial white matter and in the frontal lobes bilaterally would represent ischemia/infarction.
2. Cerebral and cerebellar atrophy.
3. Altered signal within the cervical spinal cord at the C7 vertebral level may represent cord edema/ischemia/gliosis.
4. Small posterior disc bulges with small peridiscal osteophytes at the C3-C4, C4-C5, C5-C6 and the C6-C7 levels.
5. Facetal arthropathy on the left side at the C4-C5, C5-C6 and C6-C7 levels.