Neuro Macros ImageCast

Dean Dictations 2008_JAN

For UWMC Oncall prelim reports:

IF AGREE:

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FINAL REPORT:

Agree with preliminary report. Atrophy and small vessel ischemic changes, but no acute disease evident.
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FINAL REPORT:
Agree with preliminary report. No acute disease evident. Left maxillary mucosal thickening appears chronic.
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FINAL REPORT:
Agree with preliminary report. Evolving post operative changes compared with MRI 9/7/2007 in patient s/p subtotal tumor resection.
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FINAL REPORT:
Agree with preliminary report. No fractures or subluxations
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FINAL REPORT:

Agree with preliminary report. Left frontal scalp injury but no fracture or intracranial injury.
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IF AGREE AND TECHNIQUE MISSING:

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FINAL REPORT:

TECHNIQUE: Noncontrast 5mm axial sections from skull base to vertex.
Agree with preliminary report. Atrophy and small vessel ischemic changes, but no acute disease evident.
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FINAL REPORT:

TECHNIQUE: Noncontrast 5mm axial sections from skull base to vertex.
Agree with preliminary report. No acute disease evident. Left maxillary mucosal thickening appears chronic.
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FINAL REPORT:

TECHNIQUE: Noncontrast 5mm axial sections from skull base to vertex.
Agree with preliminary report. Evolving post operative changes compared with MRI 9/7/2007 in patient s/p subtotal tumor resection.
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FINAL REPORT:

TECHNIQUE: Noncontrast 5mm axial sections from skull base to vertex.
Agree with preliminary report. No fractures or subluxations
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FINAL REPORT:

TECHNIQUE: Noncontrast 5mm axial sections from skull base to vertex.
Agree with preliminary report. Left frontal scalp injury but no fracture or intracranial injury.
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FINAL REPORT:

TECHNIQUE: Noncontrast 5mm axial sections from skull base to vertex.
Agree with preliminary report. Evolving right PCA infarct.
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FINAL REPORT:

EXAM: Maxillofacial CT noncontrast
TECHNIQUE: Noncontrast 0.625 mm axial sections through the maxillofacial structures with cornal recons
Agree with preliminary report. Left frontal scalp injury but no fracture or intracranial injury.
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FINAL REPORT:

EXAM: Maxillofacial CT post contrast
TECHNIQUE: Postcontrast 0.625 mm axial sections through the orbit and maxillofacial structures with cornal recons
Agree with preliminary report. Left peri-orbital cellulitis.  No discrete retrobulbar fluid collections to suggest orbital abscess.  There is subtle asymmetric enlargement of the left lateral rectus muscle.

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EXAM: Cervical spine CT noncontrast
TECHNIQUE: Noncontrast 2.5mm axial sections through the cervical spine with sagittal and coronal recons
FINAL REPORT:
Agree with preliminary report. No fractures or subluxations


IF DISAGREE:

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FINAL REPORT

Disagree with preliminary report. 

Results called to Dr. at
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ROUTINE CT DICTATIONS

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CT Head
EXAM: Head CT noncontrast
TECHNIQUE: Non contrast axial 5 mm contiguous sections were obtained from the vertex to the foramen magnum.
HISTORY: Headache, Trauma
COMPARISON: none.
FINDINGS:
No extraaxial fluid collections. The sulci, ventricles, and basal cisterns are normal. The brain parenchyma is intact without hemorrhage, infarcts, or mass lesions. The craniofacial structures including the sinuses, mastoids, and orbits are intact.
IMPRESSION:
Negative head CT scan
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CT Head old
EXAM: Head CT noncontrast
TECHNIQUE: Non contrast axial 5 mm contiguous sections were obtained from the vertex to the foramen magnum.
HISTORY: Headache, Trauma
COMPARISON: none.
FINDINGS:
No extraaxial fluid collections. The sulci, ventricles, and basal cisterns are normal. The brain parenchyma is intact without hemorrhage, infarcts, or mass lesions. There is mild cerebral volume loss and periventricular white mattter chronic small vessle ischemic changes not uncommon in this age group.  The craniofacial structures including the sinuses, mastoids, and orbits are intact.
IMPRESSION:
Negative head CT scan for age
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CT Head postop
EXAM: Non contrast head CT
HISTORY: Left vestibular schwannoma resection
TECHNIQUE: Non contrast axial 5 mm contiguous sections were obtained from the vertex to the foramen magnum.
COMPARISON: /2007
FINDINGS:
There has been interval resection of the left IAC mass through trans-labyrinthine approach with expected postoperative changes including small pockets air along the left CP angle cistern. There is some fat packing of the left mastoid air cells.
The brain parenchyma is otherwise intact. The mastoids, sinuses, and orbits are normal. No bony abnormalities.
IMPRESSION:
Status post left IAC mass resection with expected postoperative changes.
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EXAM: Non contrast head CT
Clinical Indication:S/P left crani for tumor
COMPARISON: Brain MRI, /08
TECHNIQUE: Noncontrast head CT with 5mm contiguous axial images from the vertex to the foramen magnum.
FINDINGS:
Patient is S/P left sided craniotomy for left temporoparietal tumor resection.  Low attenuation debris with pneumocephalus fills a resection cavity with small linear hyperdensity along the poster margin likely representing residual blood products.  Small amount of pneumocephalus is also present in the anterior cranial vault.  Low attenuation throughout the left supratentorial white matter, basal ganglia and left thalamus remains similar to the hyperintense T2 signal on prior brain MR. 
Small left extra-axial fluid collection is present along the craniotomy site.  Ventricles remain similar in size.  Basal cisterns are patent.
Orbits, sinuses and mastoids are unremarkable.
IMPRESSION:
1. Status post left craniotomy and left temporoparietal tumor resection with expected postoperative changes.  No acute intracranial hemorrhage or infarct.
2. Low attenuation in the left supratentorial white matter, basal ganglia and left thalamus remain similar to hyperintense T2 signal on brain MR. 
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CT Therapy Head
EXAM: CT therapy planning scan without contrast
HISTORY: Brain tumor
TECHNIQUE: 1.25 mm axial sections from the skull vertex to mandible within treatment planning mask. Images sent to radiation therapy planning computer.
COMPARISON: November 29, 2007 head CT scan
FINDINGS:
Patient is status post left frontal Burr hole and biopsy of
left superior frontal gyrus mass. The previously seen pneumocephalus and other acute postoperative changes have essentially completely resolved as expected. The known left frontal operculum mass is better visualized on the prior brain MRI.
No midline shift. No intra or extra axial fluid collections. No
intraparenchymal hemorrhage or infarcts. Ventricles remain stable in
size. Basal cisterns are patent.
Orbits, sinuses and mastoids are unremarkable.
IMPRESSION:
1. Status post left frontal burr hole and tumor biopsy with expected resolving postoperative changes compared with November 29, 2007.
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CT Stealth Head
EXAM: Noncontrast Head CT for surgical planning
HISTORY: Brain tumor,

TECHNIQUE: 0.625 mm axial sections from the skull vertex to mandible. Images sent to surgical planning computer.
COMPARISON: Recent head CT scan from HMC
FINDINGS:
There is grossly stable appearance of the large hemorrhagic mass centered in the left parietal lobe measureing 5 x 4 cm with surrounding vasogenic infiltration/edema anteriorly.  There is associated midline shift of 11mm and ventricular trapping.  Orbits, sinuses and mastoids are unremarkable.
IMPRESSION:
1. Stable large hemorrhagic mass centered in the left parietal lobe measuring 5 x 4 cm with surrounding vasogenic infiltration/edema anteriorly and herniation.
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CT ANGIO
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CT Head CTA
EXAM: CTA HEAD with and w/o contrast
HISTORY: headache.
TECHNIQUE: Axial 1.25 mm images were obtained of the head from the vertex to the foramen magnum without the administration of IV contrast.
Following the uneventful administration of intravenous contrast, axial 1.25 mm images were obtained of the head from the vertex to the foramen magnum. Additional post contrast 5 mm images were obtained of the head. Axial, sagittal and coronal reformations were performed and reviewed. 3-D MIP reformations of the angiographic series was performed and reviewed.
COMPARISON: /2007
FINDINGS:
Head:
No extraaxial fluid collections. The sulci, ventricles, and basal cisterns are normal. The brain parenchyma is intact without hemorrhage, infarcts, enhancement, or mass lesions. The craniofacial structures including the sinuses, mastoids, and orbits are intact.
CTA head:
No vascular abnormalities are detected. Specifically, there are no areas of aneurysmal dilation, luminal narrowing, or dissection.
IMPRESSION:
1. No intracranial abnormalities. No clear etiology for headache.
2. No intracranial vascular abnormalities are detected. Specifically, there is no evidence of aneurysmal dilation, significant luminal narrowing, or dissection.
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CT Head CTA Neck
EXAM: Head CT pre and post contrast, CTA Neck with contrast
TECHNIQUE: 
CT head pre and post contrast: 5mm contiguous axial images were obtained from the foramen Magnum to the vertex without and with contrast.
CT angiogram head/neck with contrast: 0.625 mm contiguous axial images were acquired from aortic arch to the vertex following the administration of of Visipaque without incident. 5 mm contiguous delayed axial images were acquired from the skull base to the vertex. Coronal and bilateral oblique 3D  MIP reformats of the neck were performed. 
COMPARISON: /2007
FINDINGS:
HEAD PRE AND POST CONTRAST:
No extraaxial fluid collections. The sulci, ventricles, and basal cisterns are normal. The brain parenchyma is intact without hemorrhage, infarcts, enhancement, or mass lesions. The craniofacial structures including the sinuses, mastoids, and orbits are intact.
NECK CTA WITH CONTRAST:
There is conventional arch anatomy. The origins of the common carotid and vertebral arteries are patent. Both carotid bulbs are unremarkable appearance. No hemodynamically significant stenoses. No vascular dissection or pseudoaneurysm of the cervical vessels. 
Patient is left vertebral artery dominant. Limited evaluation of the intracranial arteries demonstrates no hemodynamically significant stenoses or aneurysms.
No apical masses. Thyroid gland is unremarkable appearance. No cervical lymphadenopathy. Bones are unremarkable in appearance.
IMPRESSION:
1. Normal head CT pre and post contrast
2. Head and neck CTA: arteries intact without stenosis or other focal lesions
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CT ENT
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CT Sinuses Screen
EXAM: noncontrast sinus screening CT scan
HISTORY: sinusitis
TECHNIQUE: Noncontrast 5mm axial images through the sinuses were obtained.
COMPARISON: /2007
FINDINGS:
There is normal development and pneumatization of the paranasal sinuses.  Frontal, sphenoid, ethmoid and maxillary sinuses are clear. Osteomeatal complex are patent bilaterally. No sclerosis; skull base is unremarkable with no erosion.  Visualized soft tissues are unremarkable.
IMPRESSION:
No FINDINGS to indicate sinus disease.
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CT Sinuses
EXAM: noncontrast sinus CT scan
HISTORY: sinusitis
TECHNIQUE: 2.5mm axial images through the sinuses with coronal recons without intravenous contrast.
COMPARISON: /2007
FINDINGS:
There is normal development and pneumatization of the paranasal sinuses.  Frontal, sphenoid, ethmoid and maxillary sinuses are clear. Osteomeatal complex are patent bilaterally. No sclerosis; skull base is unremarkable with no erosion.  Visualized soft tissues are unremarkable.
IMPRESSION:
No FINDINGS to indicate sinus disease.
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CT Maxface trauma
EXAM: noncontrast maxillofacial CT scan
HISTORY: trauma
TECHNIQUE: 2.5mm axial images through the maxillofacial structures with coronal recons.
COMPARISON: /2007
FINDINGS:
The facial bones are intact without fracture. There is mild left periorbital soft tissue swelling. Visualized soft tissues including the orbits  are unremarkable.
IMPRESSION:
Left periorbital swelling but no fractures.
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CT Maxface tumor
EXAM: CT of Maxillofacial Structures with contrast
HISTORY: Mass lesion
TECHNIQUE: Contiguous 0.625 mm axial images, along with coronal reconstructions were obtained post IV contrast 
COMPARISON: none
FINDINGS:
Bony and soft tissue structures are intact. There is a 7 x 5 mm focal boney mass arising from the left lateral aspect of the frontal sinus. It demonstrates a matrix similar to chondroid. There is no invasion into the sinus or orbit. No other lesions are idenitifed. There are several subcentimeter lymph nodes in the left and right level IB nodes. Limited, visualized portions of the intracranial contents are within normal limits. No areas of abnormal enhancement. Sinuses demonstrate mild left frontal mucosal thickening.
IMPRESSION:
1. 7 x 5 mm chondroid matrix mass arising from the lateral left frontal sinus. Appearance is nonaggressive and considered to be of benign etiology. Differential diagnosis would include enchondroma or less likely, osteoid osteoma.
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CT Temporal
EXAM: noncontrast temporal bone CT scan
HISTORY: trauma
TECHNIQUE: 0.625 axial images through the temporal bones with coronal recons.
COMPARISON: /2007
FINDINGS:
The inner and middle ear structures are intact. The external auditory canal is patent. The mastoid air cells show bilateral parial opacification.
IMPRESSION: 
Negative temporal bone CT scan except for  bilateral partial matoid air cell opacification.
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CT Neck
EXAM: CT Neck with contrast
TECHNIQUE: Helical 2.5 mm axial images from the sella turcica to the clavicular fossa, following intravenous contrast. Coronal reformations were performed and reviewed.
HISTORY: Left tonsillar SCCA status post chemo and radiation therapy. 
COMPARISON: CT neck /2007.
FINDINGS:
The previously noted subtle soft tissue asymmetry involving the left tonsillar bed is stable. No new mass or enhancing lesion is detected to indicate local tumor recurrence. The spaces of the supra- and infra-hyoid neck are otherwise normal. Specifically, there is no evidence of lymphadenopathy. Visualized intracranial contents are normal. The paranasal sinuses and mastoids are clear. There is biapical lung scarring.
IMPRESSION:
Previously noted subtle soft tissue asymmetry involving the left tonsillar bed is stable. No abnormally enlarged lymph nodes by CT criterion
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CT Therapy Neck
EXAM: CT therapy planning scan with contrast
HISTORY: ACC Left Ear/Scalp
TECHNIQUE: 1.25 mm axial sections from the skull vertex to clavicles within treatment planning mask.  Images sent to radiation therapy planning computer.
COMPARISON: None
FINDINGS: There is left temporal scalp swelling and irregularity extending to the left periauricular region consistent with HISTORY of skin malignancy. There is also postoperative changes of left cervical nodal dissection with fat flap and submandibular gland and partial sternocleidal mastoid resection.  There are multiple cervical lymph nodes but none of which appear abnormally enlarged by CT criteria.  Brain parenchyma and skull appear intact and unremarkable for age.
IMPRESSION: Treatment planning CT scan demonstrates skin thickening and irregularity along the left temporal scalp and periauricular region consistent with known tumor involvement in patient status post left cervical dissection
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CT SPINE
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CT Cervical trauma
EXAM: Cervical Spine CT without contrast
TECHNIQUE:  Multiple sequential 1.25 mm slice thickness axial images were obtained from the base of the head to T3. Coronal and sagittal reformations were obtained and reviewed on the workstation.
HISTORY: Trauma 
COMPARISON: /2007
FINDINGS:
Normal alignment without subluxation. No evidence of fracture. Prevertebral soft tissues are normal. Visible lungs are clear.
IMPRESSION:
No acute cervical spine injuries.
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CT Cervical
EXAM: Cervical Spine CT without contrast
TECHNIQUE:  Multiple sequential 1.25 mm slice thickness axial images were obtained from the base of the head to T3. Coronal and sagittal reformations were obtained and reviewed on the workstation.
HISTORY: Neck pain
COMPARISON: /2007
FINDINGS:
Normal alignment without subluxation. No evidence of fracture. Prevertebral soft tissues are normal. Visible lungs are clear.
C2/3: Normal central canal and neural formanen.
C3/4:  Normal central canal and neural formanen.
C4/5: Disc/osteophyte bulge with mild central canal narrowing. Mild to moderate right and mild left neuroforaminal narrowing.
C5/6: Disc/osteophyte bulge with mild to moderate central canal narrowing. Moderate right and mild to moderate  left neuroforaminal narrowing.
C6/7: Disc/osteophyte bulge with moderate to severe central canal narrowing. Severe right and  moderate  left neuroforaminal narrowing.
C7/T1: Normal central canal and neural formanen.
IMPRESSION:
C5/6 and C6/7 moderate central canal stenosis and multilevel neuroforaminal narrowing.
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CT Cervical Myelo
EXAM: CT cervical spine post myelogram
HISTORY: Neck and arm pain
TECHNIQUE: 2.5mm axial images through the cervical spine with sagittal recons were obtained post intrathecal contrast myelogram injection.
COMPARISON: None
FINDINGS:
There is multilevel loss of disc space height consistent with degenerative change. This is most noted at C5-6. There is a grade 1 anterolisthesis of C5 on C6. There is a large, degenerative osteophyte of the C7 vertebral body.
IMPRESSION:
1. Multilevel degenerative changes
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CT thoracic
EXAM: Thoracic Spine CT without contrast
TECHNIQUE:  Multiple sequential 1.25 mm slice thickness axial images were obtained through the thoracic spine. Sagittal reformations were obtained and reviewed on the workstation.
HISTORY: Trauma 
COMPARISON: /2007
FINDINGS:
Normal alignment without subluxation. No evidence of fracture. Perivertebral soft tissues are normal.
IMPRESSION:
No acute thoracic spine injuries.
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CT Lumbar trauma
EXAM: Lumbar Spine CT without contrast
TECHNIQUE:  Multiple sequential 1.25 mm slice thickness axial images were obtained through the lumbar spine. Coronal and sagittal reformations were obtained and reviewed on the workstation.
HISTORY: Trauma 
COMPARISON: /2007
FINDINGS:
Normal alignment without subluxation. No evidence of fracture. Perivertebral soft tissues are normal.
IMPRESSION:
No acute lumbar spine injuries.
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CT Lumbar
EXAM: Lumbar Spine CT without contrast
TECHNIQUE:  Multiple sequential 1.25 mm slice thickness axial images were obtained through the lumbar spine. Sagittal reformations were obtained and reviewed on the workstation.
HISTORY: low back pain
COMPARISON: /2007
FINDINGS:
Normal alignment without subluxation. No evidence of fracture. Perivertebral soft tissues are normal.
L1/2: Normal central canal and neural formanen.
L2/3: Normal central canal and neural formanen.
L3/4:  Normal central canal and neural formanen.
L4/5: Disc/osteophyte bulge with mild to moderate central canal narrowing. Mild to moderate right and mild left neuroforaminal narrowing.
L5/S1: Disc/osteophyte bulge  but w/o significant  canal narrowing. Moderate right and mild to moderate  left neuroforaminal narrowing.
IMPRESSION:
Mild degenerative disc changes with mild central canal stenosis and L4/5 and mild to moderate L5/S1 neuroforaminal narrowing.
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CT Lumbar Postop
Exam: CT lumbar spine without contrast
TECHNIQUE: Multiple 0.625 mm axial slices were obtained from T12 through S3 and reformatted into .5 mm axial slices and bone windows.  Sagittal reformats were also obtained.
COMPARISON: CT lumbar spine, 11/30/07
FINDINGS:
Patient is S/P L4-L5 minimally invasive transforaminal lumbar interbody fusion with paired pedicle screws, spinal rods and bone graft material.  The right L5 pedicle screw tip extends just beyond the vertebral body cortex otherwise remaining hardware is in expected location.  No evidence of hardware failure.  There is a radiopaque marker related to the disc spacer at L4-L5.  Grade I spondylolisthesis of L4 on L5 has been reduced and now measures approximately 5 mm (previously measured 13 mm). Moderate central canal narrowing related to disc and ligament of flavum hypertrophy is present at the L3-L4 level.  Hardware partially obscures the central canal at L4-L5. Paravertebral soft tissues are normal.
IMPRESSION:
1. S/P L4-L5 MI-TLIF with right L5 pedicle screw extending just beyond the vertebral body cortex otherwise hardware is in expected location with no unexpected postoperative FINDINGS.
2.  Grade 1 spondylolisthesis has been reduced and now measures approximately 5 mm.

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CT Lumbar Postop vertebrectomy

HISTORY: fracture L4, s/p surgery

Examination: CT lumbar noncontrast

TECHNIQUE: 2.5 mm axil CT scan of the lumbar spine was obtained. Sagittal reformats were created.

COMPARISON: Aug 27, 2007 myelogram, intraop xrays 1/25/2008
FINDINGS:
There has been interval vertebrectomy and cage placement across the previously seen L4 burst fracture with posterior fusion from S1 through L2 with bilateral pelvic screws. On the sagittal reconstructions, there is gross anatomic alignment of the bony lumbar spine with slight anterior positioning of the cage with associated lordosis. The L4 vertebral body has been replaced the diffuse lucencies/striation. Otherwise, the vertebral body alignment is unremarkable. Pedicle screws through L2, L3, L5, and S1 appear in usual positions without evidence of canal impingement. There is usual posterior paraspinal postoperative changes with drain in place and graft material laterally.
Elsewhere, there is no evidence of bony central canal stenosis.
IMPRESSION:
Status post vertebrectomy and cage placement across the previously seen L4 burst fracture with posterior fusion from S1 through L2 with bilateral pelvic screws.

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CT CT CT CT CT CT CT CT 
 
MRI MRI MRI MRI  MRI MRI
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MRI HEAD
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MR Brain Stroke noncontrast NEGATIVE
EXAM: Noncontrast brain MRI
TECHNIQUE: Brain noncontrast Sag T1, Ax T1, T2, DWI, FLAIR, GRE  and Cor T1
HISTORY: right arm weakness
COMPARISON: /2007
FINDINGS:
No extraaxial fluid collections. The sulci, ventricles, and basal cisterns are normal. There is mild periventricular foci of T2 hyperintensity, likely secondary to chronic white matter ischemic disease. A tiny lacunar infarct is present adjacent to the left caudate head. There is mild diffuse cerebral volume loss. The brain parenchyma is intact without hemorrhage, infarcts, or mass lesions. The craniofacial structures including the sinuses, mastoids, and orbits are intact.
IMPRESSION:
Brain MRI  with mild age related chronic small vessel disease and mild volume loss but no evidence of acute disease
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MR Brain Stroke noncontrast PCA
EXAM: Noncontrast brain MRI
TECHNIQUE: Brain noncontrast Sag T1, Ax T1, T2, DWI, FLAIR, GRE  and Cor T1
HISTORY: right arm weakness
COMPARISON:  CT  Jan 26, 2007
FINDINGS:
There is a diffusion positive focus of high T2 signal and susceptibility changes along the right occipital lobe extending anteriorly into the medial temporal lobe and internal capsule posterior limb consistent with acute PCA infarct with hemorrhagic transformation.  There is a small focus of high DWI signal in the left cerebellum and a tiny one in the right cerebellum which may represent small embolic foci.  No brainstem involvment.  There is moderate local mass effect associated with the occipital-temporal swelling with 4mm of left ward midline shift and slight basal cistern asymmetry.
No extraaxial fluid collections. The sulci, ventricles, and basal cisterns are normal. The craniofacial structures including the sinuses, mastoids, and orbits are intact.
IMPRESSION:
Acute right PCA infarct with hemorrhagic transformation.
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MR Brain w Gad negative
EXAM: Pre and post contrast brain MRI
TECHNIQUE: Brain pre contrast Sag T1, Ax T1, T2, DWI, FLAIR and post contrast T1 Ax, Cor, Sag
HISTORY: Headache
COMPARISON: /2007
FINDINGS:
No extraaxial fluid collections. The sulci, ventricles, and basal cisterns are normal. The brain parenchyma is intact without hemorrhage, infarcts, or mass lesions. The craniofacial structures including the sinuses, mastoids, and orbits are intact.
IMPRESSION:
Negative brain MRI
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MR Brain stroke w Gad
EXAM: Pre and post contrast brain MRI
TECHNIQUE: Brain pre contrast Sag T1, Ax T1, T2, DWI, FLAIR and post contrast T1 Ax, Cor, Sag
HISTORY: right arm weakness
COMPARISON: /2007
FINDINGS:
No extraaxial fluid collections. The sulci, ventricles, and basal cisterns are normal. There is mild periventricular foci of T2 hyperintensity, likely secondary to chronic white matter ischemic disease. A tiny lacunar infarct is present adjacent to the left caudate head. There is mild diffuse cerebral volume loss. The brain parenchyma is intact without hemorrhage, infarcts, or mass lesions. The craniofacial structures including the sinuses, mastoids, and orbits are intact.
IMPRESSION:
Brain MRI  with mild age related chronic small vessel disease and mild volume loss but no evidence of acute disease
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MR Brain Postop
EXAM: Pre and post contrast brain MRI
TECHNIQUE: Pre-contrast axial T1, T2, FLAIR, Diffusion with ADC map; Sagittal T1. Post-contrast axial, sagittal and coronal T1. Images viewed on PACS workstation.
HISTORY: F/U GBM
COMPARISON: /2007
FINDINGS:
As before, the patient is status post left frontal craniotomy and resection. Surgical resection cavity is stable in size and appearance. Persistent hyperintense T2/flair signal surrounding the resection cavity is stable. No new nodular enhancement to suggest tumor recurrence.
Punctate scattered subcortical and mild periventricular FLAIR hyperintensities are stable in appearance. No restricted diffusion to indicate acute infarct. Vascular flow voids are normal.
No midline shift. No intra or extra axial fluid collections. Ventricles are stable in size. Basal cisterns are patent. Sinuses and mastoid air cells are clear.
IMPRESSION:
No interval change compared to prior exam dated 10/12/06. No FINDINGS to indicate disease recurrence.
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MR Brain MS
EXAM: Brain MR with and without contrast
TECHNIQUE: Using a 3T magnet, Pre-contrast sagittal FLAIR; axial T1, T2, FLAIR, diffusion with ADC map. Post-contrast axial T1. 
HISTORY: Multiple Sclerosis
COMPARISON: /2007
FINDINGS:
As before, there are multiple hyperintense FLAIR lesions again noted in the corpus collosum, left superior frontal vertex, right centrum semiovale, right medial occipital lobe adjacent to the occipital horn of the right lateral ventricle, left inferior cerebral peduncle, right pons and bilateral brachium pontis. There are no new hyperintense FLAIR lesions. Brain volume is within  normal limits for age and there is no evidence of "black  hole" lesions on the T1  weighted images.
None of the current lesions demonstrate diffusion abnormality or enhancement. No abnormal intracranial enhancement or enhancing mass lesions. Ventricles are normal in size and configuration. Basal cisterns are patent. Normal vascular flow voids. Orbits, sinuses and mastoid are unremarkable. 
IMPRESSION:
1. Multiple high T2 signal white matter lesions consistent with HISTORY of MS are stable compared with /2007. No new lesions.
2. No new hyperintense FLAIR lesions or abnormal intracranial enhancement.
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MR Brain Stealth
EXAM: Brain MR post contrast (Stealth)
HISTORY: Right frontal tumor
TECHNIQUE: MR examination of the brain was performed with IV contrast for stealth localization using sagittal T1 and axial T2 and SPGR 3D T1 images
Axial: T2, SPGR T1 post contrast
COMPARISON: /2007
FINDINGS:
There is a right frontal ring enhancing mass lesion consistent with tumor without change compared with prior scan. No extraaxial fluid collections. The sulci, ventricles, and basal cisterns are normal. The brain parenchyma is intact without hemorrhage, infarcts, or mass lesions. The craniofacial structures including the sinuses, mastoids, and orbits are intact.
IMPRESSION:
Right frontal ring enhancing mass lesion consistent with tumor
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MR Brain Sella
Exam: MRI Pituitary with/without contrast
HISTORY: Status post transphenoidal resection of residual pituitary mass.
TECHNIQUE: Brain noncontrast sag T1 and Axial FLAIR, pre and post contrast thin section T1 images through the sella
COMPARISON: MRI pituitary, 11/21/07 and CT head, 12/20/07
FINDINGS:
As before, patient is status post transphenoidal approach for residual right pituitary macroadenoma. Postsurgical changes are present within the nasal cavity, sphenoid and sella region related to recent resection. There is subtle enhancing soft tissue convexity along the right posterior aspect of the sella which likely represents post-surgical changes and less likely residual disease. Expanded sella with a fenestrated like appearance of the infundibulum remains unchanged.
Scattered subcortical hyperintense FLAIR signal in the supratentorial white matter remains unchanged. New area of hyperintense FLAIR signal within the right midbrain is due to wrap around artifact from ear.
No abnormal intracranial enhancement or restricted diffusion. No extra-axial fluid collections. Ventricles remain stable in size. Basal cisterns are patent.
Air-fluid levels are present within the maxillary sinuses. Orbits are unremarkable. Again noted is diffuse calvarial thickening.
IMPRESSION:
1. S/P transphenoidal pituitary resection for residual right sellar mass with subtle enhancing soft tissue convexity remaining in the right posterior sellar region which likely represents postsurgical changes and less likely residual tumor.
2. No restricted diffusion or abnormal intracranial enhancement.
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MR Brain Epilepsy
EXAM: MR brain with and without contrast
HISTORY: Epilepsy.
TECHNIQUE: noncontrast whole brain sagittal T1, axial T1, T2, FLAIR, GRE and thin section coronal FLAIR,STIR, and T2 temporal lobe imagse. Postcontrast T1 axial, coronal, and sagittal images of the brain
COMPARISON: MRI of brain /2007
FINDINGS:
As identified on the previous MRI, there are several focal areas of increased flair signal within the right frontal periventricular region. These are relatively unchanged in size and appearance from the prior examination. The gyri and sulci are normal in appearance. There are no areas to suggest migrational abnormalities. Cerebellar atrophy is stable. The hippocampi are well visualized. There appears to be mild volume loss on the left which is slightly more prominent than on the prior examination. No areas of abnormal enhancement.
IMPRESSION:
1. Stable cerebellar atrophy.
2. Mild assymetry of hippocampi, with the left less than the right. Although it is more prominent on today's study, it is likely reflective of imaging TECHNIQUE and not pathology progression.
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MR ANGIO
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MR Brain MRA
Exam: MRI and MRA brain without contrast
HISTORY: New effort migraine with exercise and sudden onset
COMPARISON: None
TECHNIQUE:
Noncontrast Brain MRI:  Axial T1, T2, GRE, FLAIR, and DWI with ADC map; sagittal and coronal T1. 
Noncontrast Head MRA:  3D TOF MRA of the brain with multiple 3D MIP reformations.
FINDINGS:
Brain MRI:  Gray-white differentiation is preserved.  No parenchymal signal abnormalities.  No evidence of remote intracranial hemorrhage on gradient sequence.  No restricted diffusion.  Midline structures are intact.  Posterior pituitary bright spot is in expected location.  No cerebellar tonsillar ectopia.  No extra-axial fluid collections.  No midline shift.  Ventricles are normal in size.  Basal cisterns are patent.  Normal vascular flow voids.
Orbits are normal.  There are multiple maxillary sinus mucus retention cysts. Mastoids are clear.
Head MRA:  The vertebraobasilar arteries and circle of Willis are normal in appearance.  No aneurysms, AVMs or hemodynamic significant stenoses.
IMPRESSION:
1.  Normal brain MRI and MRA exam.
2.  Bilateral maxillary sinus mucus retention cyst. 
------------------------------------------------------------
MR Brain MRA Neck
EXAM: noncontrast head MRI, head MRA, and pre and post contrast neck MRA
HISTORY: stroke
TECHNIQUE: MR/MRA examination of the head was performed without and with IV contrast using the following MR pulse sequences:
HEAD MRI:
noncontrast  sagittal  T1, axial T1,  T2, FLAIR, diffusion, and GRE 
HEAD MRA:
3D TOF MR Angiogram of the head with 3D and MIP reformations.
NECK MRA pre and post contrast:
2D TOF axial images through the neck. Dynamic post contrast Gad bolus MRA coronal slab through the neck with 3D MIP reformations. T1 axial image through the neck.
COMPARISON: CTA Head and Neck 11/26/2007
FINDINGS: 
HEAD  MR:
There is a focus of restricted diffusion in the left MCA territory consistent with acute infarct without hemorrhage. There is mild periventricular foci of T2 hyperintensity, likely secondary to chronic white matter ischemic disease. There is mild diffuse cerebral volume loss. The brain parenchyma is intact without hemorrhage, infarcts, or mass lesions. No extraaxial fluid collections. The sulci, ventricles, and basal cisterns are normal. The craniofacial structures including the sinuses, mastoids, and orbits are intact.
HEAD  MRA
No vascular abnormality is detected. Specifically, there is no evidence of aneurysmal dilatation, significant luminal narrowing, or dissection.
NECK MRA PRE AND POST CONTRAST
No vascular abnormality is detected. Specifically, there is no evidence of aneurysmal dilatation, significant luminal narrowing, or dissection.
IMPRESSION:
  1.  Left MCA acute infarct. 
2. No vascular abnormality detected within the intracranial or cervical arteries.
--------------------------------------------------------------
MRI ENT
--------------------------------------------------------------
MR IAC
EXAM: Pre and post contrast brain MRI
TECHNIQUE: Precontrast sagittal T1; axial and coronal T1 and axial T2 B FFE through the IAC's. Post contrast axial and coronal T1 through the IAC's.
HISTORY: hearing loss
COMPARISON: none
FINDINGS:
The internal auditory canals and inner ear structures appear intact. No abnormal enhancement to suggest tumor or infection. The sulci, ventricles, and basal cisterns are normal. There is mild periventricular foci of T2 hyperintensity, likely secondary to chronic white matter ischemic disease. There is mild diffuse cerebral volume loss. The brain parenchyma is intact without hemorrhage, infarcts, or mass lesions. The craniofacial structures including the sinuses, mastoids, and orbits are intact. 
IMPRESSION:
Negative temporal bone MRI pre and post contrast without evidence of tumor
--------------------------------------------------------------
MR IAC postop
EXAM: Pre and post contrast brain MRI
TECHNIQUE: Precontrast sagittal T1; axial and coronal T1 and axial T2 B FFE through the IAC's. Post contrast axial and coronal T1 through the IAC's.
HISTORY: Status post resection of acoustic neuroma
COMPARISON:  none
FINDINGS:
As before, patient status post left suboccipital craniotomy and resection of posterior wall of the left IAC and left mastoidectomy with fat packing and granulation tissue. There are stable postsurgical changes in the posterior fossa and left IAC.  Small focus of nodular enhancement along the superior wall of the left IAC remains stable compared to 10/04/05 and likely represents scar given stability of appearance, although cannot entirely exclude tiny residual tumor. No new enhancing mass lesions within the IAC or cerebellopontine angle.
Ventricles are stable in size. Maxillary and sphenoid sinuses are clear.
IMPRESSION:
Stable postsurgical changes with no new enhancing mass lesions in the IAC's or posterior fossa.
--------------------------------------------------------------
MR Neck
EXAM: Pre and post contrast Neck MRI
TECHNIQUE: Precontrast sagittal T1; axial and coronal T1 and axial STIR through the neck. Post contrast axial and coronal T1 through the neck.
HISTORY: SCCA left maxillary sinus status post chemoradiation.
COMPARISON: /2007
FINDINGS:
As before, an infiltrative, T2 hyperintense, enhancing lesion is present arising from the left maxillary sinus and extending into the left masticator space and pterygopalatine fossa with additional involvement of the clivus, left cavernous sinus, and left orbital apex. Since the previous examination, there is increased involvement of the left lateral maxillary sinus and soft tissues of the left cheek manifested by a 2.1 x 3.6 cm enhancing lesion. A focal area of decreased signal and enhancement is now present within the central and left lateral clivus, possibly representing the area of gamma knife. Within the adjacent right clivus, there is increased T2 signal and contrast enhancement, consistent with progression of residual clival tumor or edema and inflammation from the gamma knife.
Visualized intracranial contents are normal.
The remainder of the paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
Stable postsurgical changes with no evidence of recurrent tumor or new lymph nodes
--------------------------------------------------------------
MR TMJ
EXAM: MRI temporomandibular joint. 
HISTORY: Right-sided pain.
TECHNIQUE:  Sagittal coronal open and closed mouth views of the right and left temporomandibular joint were obtained.
COMPARISON: None
FINDINGS:
The closed position of the right temporomandibular joint demonstrates anterior displacement of the disc.  There is less than 50% reduction upon open mouth views, as the majority of the disc remains anterior to the mandibular head.  The left side also demonstrates anterior disc displacement on closed mouth view, with no reduction on open mouth view.  Limited, visualized portions of the intracranial contents are within normal limits.  Limited, visualized vascular flow voids are patent.
IMPRESSION:
1.  Right temporomandibular disk displacement with less than 50% reduction on open mouth views.
2.  Left temporomandibular disk displacement with no apparent reducaiton on open mouth views.
--------------------------------------------------------------
--------------------------------------------------------------
MRI SPINE
--------------------------------------------------------------
MR Cervical
EXAM: MR cervical spine without gadolinium
TECHNIQUE:  sagittal T1, sagittal T2, axial T2 through the cervical spine
HISTORY: Neck pain
COMPARISON: /2007
FINDINGS:
Normal alignment without subluxation. No evidence of fracture. Prevertebral soft tissues are normal. The spinal cord is intact.
C2/3: Normal central canal and neural formanen.
C3/4:  Normal central canal and neural formanen.
C4/5: Disc/osteophyte bulge with mild central canal narrowing. Mild to moderate right and mild left neuroforaminal narrowing.
C5/6: Disc/osteophyte bulge with mild to moderate central canal narrowing. Moderate right and mild to moderate  left neuroforaminal narrowing.
C6/7: Disc/osteophyte bulge with moderate to severe central canal narrowing. Severe right and  moderate  left neuroforaminal narrowing.
C7/T1: Normal central canal and neural formanen.
IMPRESSION:
C5/6 and C6/7 moderate central canal stenosis and multilevel neuroforaminal narrowing.
--------------------------------------------------------------
MR Cervical Gad
EXAM: MR cervical spine post gadolinium
TECHNIQUE:  postcontrast  sagittal T1, PD, STIR, T2, and axial T2 and T1 images through the cervical spine
HISTORY: multiple sclerosis
COMPARISON: /2007
FINDINGS:
The spinal cord is again intact without abnormal foci to suggest demyelination.
Normal alignment without subluxation. No evidence of fracture. Prevertebral soft tissues are normal.
C2/3: Normal central canal and neural formanen.
C3/4:  Normal central canal and neural formanen.
C4/5: Disc/osteophyte bulge with minimal central canal narrowing. Mild right neuroforaminal narrowing.
C5/6: Disc/osteophyte bulge with minimal central canal narrowing. Mild left neuroforaminal narrowing.
C6/7: Disc/osteophyte bulge with mild central canal narrowing. Mild bilateral neuroforaminal narrowing.
C7/T1: Normal central canal and neural formanen.
IMPRESSION:
Intact spinal cord without focal lesions stable compared with /2007. Mild degenerative disc changes.
--------------------------------------------------------------
MR Thoracic
EXAM: MR thoracic spine without gadolinium
TECHNIQUE:  sagittal T1, sagittal T2, axial T2 through the thoracic spine
HISTORY: Back pain
COMPARISON: /2007
FINDINGS:
Normal alignment without subluxation. No evidence of fracture. Perivertebral soft tissues are normal.
IMPRESSION:
Normal thoracic spine MRI.
--------------------------------------------------------------
MR Lumbar Negative
EXAM: MR lumbar spine without gadolinium
TECHNIQUE:  sagittal T1, sagittal T2, axial T1, axial T2 through the lumbar spine
HISTORY: Back pain
COMPARISON: /2007
FINDINGS:
Normal alignment without subluxation. No evidence of fracture. Perivertebral soft tissues are normal.
IMPRESSION:
Normal lumbar spine MRI.
--------------------------------------------------------------
MR Lumbar 
EXAM: MR lumbar spine without gadolinium
TECHNIQUE:  sagittal T1, sagittal T2, axial T1, axial T2 through the lumbar spine
HISTORY: Back pain
COMPARISON: /2007
FINDINGS:
Normal alignment without subluxation. No evidence of fracture. Perivertebral soft tissues are normal.
The conus ends normally at L1 and the equda equina nerve roots appear intact.
There is mild disc dessication and hight loss at the L3/4, L4/5, and L5/S1 levels. There are mild modic type 2 endplate changes at L4/5 and L5/S1.
L1/2: Normal central canal and neural formanen.
L2/3: Normal central canal and neural formanen.
L3/4:  Normal central canal and neural formanen.
L4/5: Disc/osteophyte bulge with mild to moderate central canal narrowing. Mild to moderate right and mild left neuroforaminal narrowing.
L5/S1: Disc/osteophyte bulge  but w/o significant  canal narrowing. Moderate right and mild to moderate  left neuroforaminal narrowing.
IMPRESSION:
Mild degenerative disc changes with mild central canal stenosis and L4/5 and mild to moderate L5/S1 neuroforaminal narrowing.
--------------------------------------------------------------
MR Lumbar Gad
EXAM: MR lumbar spine pre and post gadolinium
TECHNIQUE:  noncontrast sagittal T1, sagittal T2, axial T1, axial T2 and postcontrast T1 axial and sagittal images through the lumbar spine
HISTORY: Back pain, prior surgery
COMPARISON: /2007
FINDINGS:
Normal alignment without subluxation. No evidence of fracture. Perivertebral soft tissues are normal.
The conus ends normally at L1 and the equda equina nerve roots appear intact.
There is mild disc dessication and hight loss at the L3/4, L4/5, and L5/S1 levels. There are mild modic type 2 endplate changes at L4/5 and L5/S1.
There are postoperative changes at the left L4/5 level consistent with laminotomy and possible discectomy.
L1/2: Normal central canal and neural formanen.
L2/3: Normal central canal and neural formanen.
L3/4:  Normal central canal and neural formanen.
L4/5: Disc/osteophyte bulge with mild to moderate central canal narrowing. Mild to moderate right and mild left neuroforaminal narrowing.
L5/S1: Disc/osteophyte bulge  but w/o significant  canal narrowing. Moderate right and mild to moderate  left neuroforaminal narrowing.
IMPRESSION:
Mild degenerative disc changes with mild central canal stenosis and L4/5 and mild to moderate L5/S1 neuroforaminal narrowing.
--------------------------------------------------------------
EXAM: MR lumbar spine pre and post gadolinium
TECHNIQUE:  noncontrast sagittal T1, sagittal T2, axial T1, axial T2 and postcontrast T1 axial and sagittal images through the lumbar spine
HISTORY: Back pain, prior surgery
COMPARISON:  none
FINDINGS:
Normal alignment without subluxation except for minor degenertive retrolithesis at L5/S1. No evidence of fracture. Perivertebral soft tissues are normal.
The conus ends normally at L1 and the equda equina nerve roots appear intact.
There is mild disc dessication and hight loss at the L4/5, and ,more severe height loss at L5/S1.
There are postoperative changes at the left L5/S1 level consistent with laminotomy and possible discectomy.
L1/2: Normal central canal and neural formanen.
L2/3: Normal central canal and neural formanen.
L3/4:  Normal central canal and neural formanen.
L4/5: Disc/osteophyte bulge with a possible small right paracentral component of extrusion inferiorly but without significant central canal narrowing. No significant neuroforaminal narrowing.
L5/S1:  Minor  disc/osteophyte bulge  but w/o significant  canal narrowing. Enhancing left anteior epidural presumed scar tissue partially surrounds the left S1 root but it is not displaced.  There is moderate bilateral neuroforaminal narrowing.
IMPRESSION:
Mild degenerative disc changes at L4/5 and post operative changes at L5/S1 but without significant central canal stenosis.  Post operative changes at left L5/S1 include enhancing presumed scar tissue along the left S1 nerve root. Moderate L5/S1 bilateral neuroforaminal narrowing.
--------------------------------------------------------------
MR total spine
EXAM: MRI cervical, thoracic and lumbar spine with and without contrast
HISTORY: Metastatic breast cancer.
TECHNIQUE: Pre-and postcontrast sagittal and axial T1 and T2 weighted images through the cervical, thoracic and lumbar spine were obtained with and without gadolinium.
COMPARISON: MRI lumbar spine June 18, 2007 MRI thoracic spine November 3, 2006
Cervical spine:
Vertebral body and disc space heights are well maintained. There is no evidence of fracture or dislocation. No areas of abnormal enhancement. Spinal cord signal intensity is homogeneous. There is no spondylitis or spondylolisthesis. Limited, visualized portions of the posterior fossa are within normal limits. Minimal degenerative changes are noted.
Thoracic spine:
The vertebral body and disc space heights are well maintained. There is no evidence of fracture or dislocation. No abnormal enhancement. Spinal cord signal intensity is homogeneous. No spondylitis or spondylolisthesis.
Lumbar spine:
Vertebral body and disc space heights are well maintained. There is no fracture or dislocation. Spinal cord signal intensity is homogeneous and the conus ends at L1. There remains a 1.8 x 0.8 cm extra medullary, intradural enhancing focus at the level of L2. It is unchanged in size and appearance compared to the prior examination.
IMPRESSION:
Stable 1.8 x 0.8 cm extramedullary, intradural enhancing focus at L2. Given its stability over the course of one year, metastatic process is less likely etiology. Differential remains likely as a schwannoma or ependymoma.
--------------------------------------------------------------
MRI NEUROGRAM
--------------------------------------------------------------
MR Brachial Plexus
EXAM: MR right brachial plexus neurogram without gadolinium
TECHNIQUE:  sagittal and coronal noncontrast  T1, STIR, SPAIR through the right brachial plexus
HISTORY: Arm weakness
COMPARISON: none
FINDINGS:
The brachial plexus nerves show normal size and signal intenisty without evidence of swelling or edema.  No evidence of abnormal masses or nerve impingement.  The adjacent soft tissues are normal and there is no evidence of denervation.
IMPRESION:
Normal right brachial plexus neurogram.
--------------------------------------------------------------
MR Wrist
EXAM: MR right wrist neurogram without gadolinium
TECHNIQUE:  axial T1, STIR, SPAIR and coronal T1 images through the right wrist
HISTORY: carpal tunnel
COMPARISON: none
FINDINGS:
The right median nerve shows moderate flattening within the carpal tunnel and moderately abnormal high signal on the STIR axial images beginning at the carpal tunnel level and extending approximately 2 cm proximal.  No evidence of abnormal signal in the palmar bursa or of muscle denervation.  The median nerve is in normal position withoug evidence of interposition within the tendons.  The carpal and other visualized bones are unremarkable except for a few incidental carpal subcondral cysts..
IMPRESION:
Moderate right median nerve flatenning and high STIR signal consistent with carpal tunnel neuropathy.

--------------------------------------------------------------
MR Elbow
EXAM: MR right elbow neurogram without gadolinium
TECHNIQUE:  axial T1, STIR, SPAIR and coronal T1 images through the right elbow
HISTORY: ulnar neuropathy
COMPARISON: none
FINDINGS:
The right ulnar nerve shows normal size and configuration at the elbow joint, but a mild degree of abnormal high STIR signal at the medial epicondyle and extending approximately 2cm proximal.   No evidence of adjacent bony abnormality or of muscle denervation.
IMPRESION:
Mildly elevated STIR signal in the right ulnar nerve at the medial epicondyle.
--------------------------------------------------------------
MR Sacral Plexus
EXAM: MR sacral plexus neurogram without gadolinium
TECHNIQUE:  axial and coronal noncontrast  T1, STIR, SPAIR through the pelvis
HISTORY: sacral plexus neuropathy
COMPARISON: none
FINDINGS:
The sacral plexus nerves show normal size and signal intenisty without evidence of swelling or edema.  No evidence of abnormal masses or nerve impingement.  The adjacent soft tissues are normal and there is no evidence of denervation.
IMPRESION:
Normal sacral plexus neurogram.
  ------------------------------------------------------
MR MR MR MR MR MR MR MR
 
CR CR CR CR CR CR CR CR CR
  ------------------------------------------------------
Xray Cervical
EXAM: 2 views cervical spine
HISTORY: Neck pain
COMPARISON: None
FINDINGS:
Normal configuration and alignment. No fractures or subluxations. Minimal degenerative changes at C4/5, C5/6, and C6/7.
  ------------------------------------------------------
Xray Cervical trauma
EXAM: AP, odontoid and lateral views cervical spine (3 views total)
HISTORY: trauma
COMPARISON: None
FINDINGS: No malalignment or acute fractures. Soft tissues are unremarkable.
Disc space narrowing and osteophyte formation at C4-5 indicates disk degeneration
  ------------------------------------------------------
Xray Thoracic
EXAM: 2 views thoracic spine
HISTORY: back pain
COMPARISON: None
FINDINGS:
Normal configuration and alignment. No fractures or subluxations. 
----------------------------------------------------------
Xray Lumbar
EXAM: 2 views lumbar spine
HISTORY: Back pain
COMPARISON: None
FINDINGS:
5 lumbar type vertebral bodies. No focal malalignment. No fractures. Normal visible soft tissues.
Multilevel disc and joint degeneration, worst at L5-S1, with moderate disc space narrowing and osteophytosis.
---------------------------------------------------------
Xray spine postop
EXAM: AP and lateral views of the thoracic and lumbar spine
HISTORY: Status post L2 corpectomy with intervertebral cage and posterior fusion
COMPARISON: Lumbar plain films, /08
FINDINGS: Patient has undergone interval L2 corpectomy with intervertebral cage.  PSIF from T11-L3 remains unchanged.  Alignment remains unchanged.  No evidence of hardware failure.
----------------------------------------------------------
Xray Skull (for shunt)
EXAM: Skull, 1 view
HISTORY: VP shunt
TECHNIQUE: A single lateral view the skull was obtained.
COMPARISON: Shunt series December 11, 2007
FINDINGS: A VP shunt dial is identified approximately 1.5 cm superior to the sella turcica.  Limited, visualized portions of the intracranial tubing appear intact. Endotracheal tube is present. Osseous structures are intact.


Xray pump check
EXAM: AP and lateral views of the thoracic and lumbar spine
HISTORY: Pump check
COMPARISON: Pump check, 6/14/05
FINDINGS/IMPRESSION: 
The thoracic and lumbar  vertebral bodies appear intact with mild lower lumbar degenerative changes. 
A pump is present within the left lower quadrant superficial soft tissues.  Catheter enters the spinal canal at the L2 vertebral level and ascends cranially to the T6 vertebral level.  The catheter appears intact along its entire visualized course with no apparent disc connections or kinks. 
There is an electronic neurostimulator present in the right lower with small caliber wires entering the spinal canal at T11-T12 level with electrode terminating at T8 vertebral level.
The paravertebral soft tissues are normal.
---------------------------------------
EXAM: Shunt series
HISTORY: VP shunt.
TECHNIQUE: Two views of the skull, thoracic and lumbar spine and abdomen were obtained.
COMPARISON: Shunt series December 11, 2007
FINDINGS:
As previous identified, patient status-post craniotomy.  Shunt valve is identified in the left soft tissues of the head.  The intracranial most portion of the shunt catheter is not well visualized.  However remaining portions of the tubing visualize coursing through the skull, left hemithorax, left and right abdomen and mid pelvis are intact.  There is no apparent discontinuity or shunt catheter kinking.
---------------------------------------
 
CR CR CR CR CR CR CR CR CR
 
RF RF RF RF RF RF RF RF RF RF
  ------------------------------------------------------
Spinal methotrexate
EXAM: Fluoro guided lumbar spinal puncture with Methotrexate infusion
HISTORY: AML, intrathecal chemotherapy
COMPARISON: /07
TECHNIQUE: Written informed consent was obtained from the patient after risks/benefits had been discussed and all questions had been answered. Risks discussed included bleeding, infection, nerve damage, and headache.
Under fluoroscopy, the L2-3 level was localized. The overlying skin was prepped, draped, and anesthetized. A 20G needle was advanced into the subarachnoid space with return of clear fluid. A total of 15 cc of fluid was aspirated in aliquots and sent to Pathology. 12 mg of methotrexate was then injected, and the needle was removed.
There were no immediate complications.
I, Dr. , was personally present for the entire procedure.
FINDINGS: Spot view shows needle in expected position and intact lumbar vertebral bodies
IMPRESSION: Successful lumbar puncture with methotrexate injection.
----------------------------------------------------------
Spinal puncture
EXAM: Fluoro guided lumbar spinal puncture
HISTORY: mental status changes with suspected meningitis
COMPARISON: none
TECHNIQUE: Written informed consent was obtained from the patient after risks/benefits had been discussed and all questions had been answered. Risks discussed included bleeding, infection, nerve damage, and headache.
Under fluoroscopy, the L2-3 level was localized. The overlying skin was prepped, draped, and anesthetized. A 20G needle was advanced into the subarachnoid space with return of clear fluid. A total of 15 cc of fluid was aspirated in aliquots and sent to Pathology.
I, Dr. , was personally present for the critical portion of the procedure including needle puncture into the spinal fluid and was immeadiately available for the remainder.
FINDINGS: Spot view shows needle in expected position and intact lumbar vertebral bodies
IMPRESSION: Successful fluoro guided lumbar puncture.
----------------------------------------------------------
Spinal cisternogram
EXAM:  Fluoro guided  Lumbar spinal puncture for nuclear medicine cisternogram.
HISTORY: Spontaneous intracranial hypotension, evaluate for CSF leak
COMPARISON: none
TECHNIQUE: Written informed consent was obtained from the patient after risks/benefits had been discussed and all questions had been answered. Risks discussed included bleeding, infection, nerve damage and headache.
Under fluoroscopy, the L3-4 level was localized. Overlying skin was prepped, draped and anesthetized. A 20g spinal needle was advanced into the subarachnoid space with return of clear fluid. At this point, nuclear medicine arrived to inject the radiotracer for the nuclear medicine cisternogram study.
There were no immediate complications.
I, Dr. , was personally present for the entire procedure.
FINDINGS: Spot view shows needle in expected position and intact lumbar vertebral bodies. For nuclear medicine cisternogram results please see separate report.
IMPRESSION: Technically successful lumbar spinal puncture for nuclear medicine cisternogram.
----------------------------------------------------------
Myelo Cervical
EXAM: Cervical myelogram.
HISTORY: C4 radiculopathy, HISTORY of cervical fusion.
COMPARISON: none
TECHNIQUE: Following description of the risks, benefits, and alternatives, including infection, bleeding, nerve injury, seizure, and headache, informed consent was obtained and placed in the patient's chart.  The patient was placed on the examination table in the prone position, and the skin over the L3/4 disc space was prepped and draped in the usual sterile fashion. Under fluoroscopic guidance, a 20g spinal needle was advanced into the thecal sac. After confirmation of position by injection of a small amount of contrast, 10 cc of Isovue 300-M contrast was infused into the spinal canal during intermittant fluoroscopic observation. The fluoroscopy table was subsequently tilted headdown during intermittent fluoroscopic confirmation of contrast entering the thoracic and cervical spine. This was followed by acquisition of multiple views of the cervical spine in various orientations, including AP, lateral, two each bilateral obliques. The patient was then transported to the CT suite for cervical spine CT scan, which is dictated under separate report. There were no immediate complications.
I, Dr. , was personally present for the entire procedure. 
FINDINGS:
Lateral images demonstrates mild ventral, extra axial dural impression, probably due to an osteophyte at C3/4. C2/3 and C4/5 demonstrate no significant dural impression. The C5 through T1 cannot be evaluated as the swimmers views were lost. AP, bilateral oblique images demonstrate right C4 mild to moderate nerve root sleeve compression and moderate nerve root sleeve compression of left C4 and C5. Additionally, there is mild nerve root sleeve compression at C7. Right C5, bilateral C6,nerve sleeves are normally opacified. C2 and C3 cannot be evaluated.
IMPRESSION: 
1. Technically successful cervical myelogram using lumber approach.
2. Mild ventral, extra axial dural IMPRESSION at C3/4.
3. Mild to moderate right C4 nerve root sleeve compression, moderate left C4 and C5 nerve root sleeve compression and mild bilateral C7 nerve root sleeve compression.
-----------------------------------------------------
Myelo Lumbar
EXAM: Lumbar myelogram.
HISTORY: Degenerative scoliosis, low back pain.
COMPARISON: none
TECHNIQUE: Following description of the risks, benefits, and alternatives, including infection, bleeding, nerve injury, seizure, and headache, informed consent was obtained and placed in the patient's chart.  The patient was placed on the examination table in the prone position, and the skin over the L3/4 disc space was prepped and draped in the usual sterile fashion. Under fluoroscopic guidance, a
20g spinal needle was advanced into the thecal sac. After confirmation of position by injection of a small amount of contrast, 15 cc of Isovue 200-M contrast was infused into the spinal canal during intermittant fluoroscopic observation. This was followed by acquisition of multiple views of the lumbar spine in various orientations, including AP, lateral, two each bilateral obliques. The patient was then transported to the CT suite for lumbar spine CT scan, which is dictated under separate report. There were no immediate complications.
I, Dr. , was personally present for the entire procedure.
FINDINGS:
Intrathecal contrast in the lumbar spine demonstrates multiple  ventral impressions of the dural sac. Please see CT scan report for further details.
IMPRESSION: 
1. Technically successful lumbar myelogram.
2. Multilevel degenerative disc disease and levoconvex scoliosis. Please see CT report for details.
------------------------------------------------------

OR spots
------------------------------------------------------
Xray spine OR
EXAM: Spine, OR procedure.
Clinical indication: Spinal stenosis
COMPARISON: 11/14/07.
Report: Three intraoperative spot fluoroscopic images obtained. Images
show laminectomy and posterior spinal fusion from C3-C6 on what is assumed to be a right and C3-7 on what is assumed to be the left (frontal image is not labeled as to sidedness).  As before, the patient is status post C4-C7 ACDF.
------------------------------------------------------------------------------
Xray spine postop
EXAM: Intraoperative two views.
HISTORY: Fixation.
TECHNIQUE: Two intraoperative views of the lower cervical spine were obtained.
COMPARISON: None
FINDINGS:
Two intraoperative views of a C5-6 and C6-7 fixation are presented for evaluation. Pedicle screws and plates are intact without evidence of failure. Good anatomic alignment.
--------------------------------------------------------------------------

Spine Intervention spots
------------------------------------------------------------------------
EXAM: Fluoroscopy-Guided Injection
HISTORY: Pain
TECHNIQUE: Lumbosacral spine, 1 view
FINDINGS:
Image from the guidance procedure shows appropriate needle position with contrast injection at the sacrum, without evident complication.
------------------------------------------------------------------------
EXAM: Fluoroscopy-Guided Injection
HISTORY: Pain
TECHNIQUE: Lumbosacral spine, 1 view
FINDINGS:
Image from the guidance procedure shows appropriate needle position with contrast injection at the lumbosacral junction on the right,
without evident complication.
------------------------------------------------------------------------
EXAM: Coccyx, 1 static view from fluoroscopy-guided injection procedure
HISTORY: Pain
COMPARISON: None
FINDINGS: Static view from fluoroscopy-guided injection procedure confirms appropriate needle placement.
-----------------------------------------------------------------------
EXAM: Fluoroscopic procedure.
HISTORY: Right S1 radiculopathy.
COMPARISON: None.
FINDINGS: Single fluoroscopic static image of the lumbosacral junction is submitted for documentation status post right S1 nerve root injection.
------------------------------------------------------------------------
EXAM: Fluoroscopic guided procedure.
HISTORY: Right L5/S1 facet injection for pain.
COMPARISON: None.
FINDINGS: Single fluoroscopic static image of portion of the lower lumbar spine is submitted for documentation status post facet joint injection.
-------------------------------------------------------

ANGIO  ANGIO  ANGIO  ANGIO

------------------------------------------------------
CEREBRAL ANGIO ñ DIAGNOSTIC FOR VASCULITIS (NEGATIVE)
----------------------------------------------------------
EXAM: cerebral angiogram
HISTORY: 49 y/o female with strokes and concern for vasculitis.
COMPARISON: MR Brain, 7/13/07
PROCEDURE: Written informed consent was obtained from the patient's  husband, Mark Richter, following a detailed description of the  procedure, including the risks and benefits. Risks discussed  included, but were not limited to bleeding, infection, vascular  damage, adverse contrast reaction, and stroke. All questions were  answered prior to signature of the informed consent.  

The patient was brought to the angiography suite and placed on the  table in the supine position. The bilateral groins were then prepped  and draped in usual sterile fashion. The left common femoral artery  was accessed using a micropuncture access needle and a 4 Fr sheath was placed and flushed using the seldinger technique.  

With the assistance of an .035 glide wire and digital road map  technique, the following vessels were selectively catheterized with a  4 french vertebral artery catheter: Right internal carotid; Left  internal carotid; and Left vertebral artery. Digital subtracted  angiograms were then performed intracranially in various projections  and magnified views.   The catheter and sheath were removed and adequate hemostasis was  achieved at the groin puncture site. The patient tolerated the  procedure well without complications and left the angiography suite  neurologically unchanged.  

I, Dr., attending neuroradiologist was personally present  throughout the entire procedure.  

FINDINGS:
Right internal carotid artery (AP, lateral): Vessels are normal in  size and caliber with normal arterial, capillary and venous phase.  No aneurysms or vascular malformations. The right  ICA, ACA, MCA and their branches are normal in appearance.
Left internal carotid artery (AP, lateral): Vessels are normal in  size and caliber with normal arterial, capillary and venous phase. No aneurysms or vascular malformations. The left ICA, ACA, MCA and  their branches are normal in appearance.  
Left vertebral artery (Townes, lateral,): Vessels are normal in size  and caliber with normal arterial, capillary and venous phase. The  patient is left vertebral artery dominant. The basilar, its branches,  and both superior cerebellar arteries are normal in appearance. No  basilar aneurysm or vascular malformations.  Visualized right vertebral artery is normal with no aneurysm.

IMPRESSION:
1. No angiographic findings of vasculitis. 
2. No aneurysms or vascular malformations.
-------------------------------------------------------
CEREBRAL ANGIO ñ DIAGNOSTIC FOR MASS
------------------------------------------------------

EXAM: Cerebral angiogram.
HISTORY: Cerebellar lesion, ataxia.
COPARISON: MR Brain 9/18/2007.
 
PROCEDURE:
Written informed consent was obtained from the patient after a  lengthy discussion of the risks and benefits of the procedure. Risks  discussed included but are not limited to bleeding, pain, infection,  vascular damage, allergic reaction, and stroke. The patient was  brought to the angiography suite, placed in the supine position, and  prepped and draped in the usual fashion. Conscious sedation was  administered by the Radiology nursing staff.
The right common femoral artery was punctured using an 18 gauge  single wall needle. Using Seldinger technique a 4 French sheath was  inserted. Vessels, left CCA, right vertebral, and right CCA were  selectively catheterized using a Glidewire and 4 French vertebral  catheter. Selective injections in multiple projections were performed  in each of these arteries.    The patient tolerated the procedure well without complication.   The catheter and sheath were removed and hemostasis was obtained with  manual compression. The patient left the angiography suite  neurologically unchanged.  

I, Dr., the attending neuroradiologist, was present for the  entire procedure.

FINDINGS:
Right common carotid artery: (PA, Lateral). Normal terminal ICA. Normal anterior and middle cerebral artery  branches, with similarly normal capillary and venous phases. No  aneurysm or other vascular anomaly. No vasospasm. No significant  vascular contribution to the posterior fossa.
Left common carotid artery: (PA, Lateral). Normal terminal ICA. Normal anterior and middle cerebral artery  branches, with similarly normal capillary and venous phases. No  aneurysm or other vascular anomaly. No vasospasm. No significant  vascular contribution to the posterior fossa.  
Right vertebral artery: (lateral, Townes ). A large, ovoid area of mild vascular blush is present within the  posterior fossa adjacent to the tentorium correlating to the ring  enhancing mass seen on the MR examination. There is no enlarged  vessel supplying this area of blush. There is no arterial venous  shunting through this area. There is no significant contribution to  this area via collaterals from the anterior circulation.  Otherwise normal right vertebral and basilar artery. The dural  sinuses are grossly patent. 

IMPRESSION:
1. Large, ovoid area of mild vascular blush within the posterior  fossa adjacent to the tentorium correlating with the ring enhancing  mass seen on the MR examination. No AV shunting is detected. There  is no enlarged vessel feeding this area. There is no collateral  blood flow from the anterior circulation.
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CEREBRAL ANGIO ñ TUMOR EMBO
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EXAM: Diagnostic cerebral angiogram and embolization
HISTORY: Recurrent gliosarcoma around left ear and neck.
Preoperative embolization.
COMPARISON: Brain MRI, 3/12/07

PROCEDURE:
Informed consent was obtained by the patient and placed  in patient chart. Patient was brought to the angiography suite and  placed supine on the table. General anesthesia was administered.  Right groin was draped and prepped in sterile fashion. Using  seldinger technique an 18 G needle was used for vascular access in  the right femoral artery with placement of a 4 Fr sheath.

Using a 4  Fr Vertebral catheter and .035 glidewire, diagnostic cerebral  angiogram was performed with selective catheterization of the  following vessels: Right CCA, Left vertebral, Left ICA and ECA.   Using a .014 Excelsior microcatheter and Synchro wire, selective  catheterization of the left posterior auricular and occipital  arteries were performed and embolization performed using 250-350  micron PVA particles.   Sheath was pulled in angiography suite with no complications and  patient was transferred to PACU.  

I, Dr. , Neurointerventional Attending, performed the entire  procedure and was assisted by Dr. , Fellow Neuroradiology.  

Findings:  
Right CCA: There is normal filling and appearance of the ICA, ECA  and distal branches. No aneurysms, AVMs or occlusion. Normal  arterial, capillary and venous phases. At the junction of the left  transverse sigmoid sinus there is focal narrowing which may be  related to intracranial tumor compression. There is prominent nasal  blush of unclear clinical significance.  

Left ICA: There is normal filling and appearance of the ICA and  distal branches including both A2 segments. There is a left fetal  PCA origin. No aneurysms, AVMs or occlusion. There is normal  arterial and venous phases with hypoperfusion on the capillary phase  in the left parietal angular region which may be related to prior  resection or infarct. As before, there is focal narrowing at the  junction of the left transverse sigmoid sinus, but sinus remains  patent. There is reflux into the ECA and branches.  

Left ECA: There is normal filling of the ECA and branches. However,  the superficial temporal artery is not visualized. There is tumor  blush in the left temporal occipital region supplied by collateral  branches off the STA, posterior auricular and occipital arteries.   Left Vertebral: There is normal filling of the left vertebral  artery, basilar and right PCA with reflux into the right vertebral  artery. There is no filling of the left P1 segment due to fetal PCA  origin. Normal arterial, venous and capillary phases.  

Left CCA (post-embolization): There is mild persistent tumor blush  along the anteroinferior left temporal occipital region via small  branches off the occipital artery in proximity to the vertebral  artery anastomosis; otherwise previous tumor blush supplied by the  posterior auricular artery has been successfully embolized.  Incidentally noted is a small plaque in the proximal left ICA just  distal to the bifurcation, but with no significant stenoses.

IMPRESSION:
1. Successful tumor embolization via the left posterior auricular  and distal occipital artery branches with mild persistent tumor blush  along the anteroinferior temporal occipital region from small  branches off the occipital artery in proximity to the vertebral  artery anastomosis.
2. Focal narrowing at the junction of the left transverse sigmoid  sinus may be related to intracranial tumor compression, but no sinus  thrombosis.
3. Small plaque in the proximal left ICA just distal to bifurcation  with no significant stenoses.
4. Left fetal PCA origin.  
Findings were discussed with Dr. Rostomily immediately after the  embolization.
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SPINAL ANGIO
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EXAM: Spinal angiogram with embolization
HISTORY: Metastatic squamous cell cancer with vertebral mets involving T7 and
T8; anticipating surgery; pre-operative embolization.
COMPARISON: MRI of the spine from February 12, 2008.

TECHNIQUE:
The risks and benefits of the procedure were discussed with the  patient and written informed consent obtained.  The patient was brought into the Angiography suite and general  endotracheal anesthesia was provided by the Anesthesiology Service.  Bilateral groins were prepped and draped in standard sterile fashion.  The right common femoral artery was punctured using a single wall 18-gauge needle. A 5-French sheath was then placed using Seldinger  technique.  

A Chuang-II catheter was then utilized over a glide wire  to select the following vessels: Left T6, T7, T8, and T9, and right  T7, T8 and T9 intercostal arteries. Following this, the catheter was  then used to select the right T7 artery.

At this point, a Renegade  microcatheter was used with the help of a Synchro-200 guide wire to  select the distal right T7 artery followed by embolization with PVA  particles (250-350).  Following this, a Tornado coil was deployed  into the vessel. The right T8 intercostal artery was then similarly  selected using the Renegade microcatheter and embolized using PVA  particles followed by a single Tornado coil.  The microcatheter was then used to select the left T7 artery followed by the deployment of a single Tornado coil. The catheter and sheath were then removed followed by manual  compression and hemostasis. There were no immediate complications.   

I, Dr., the attending radiologist, was personally present for the entire procedure.

FINDINGS: 
LEFT T6 (AP): No vascular blush noted. No aneurysms or vascular  malformations.
LEFT T7 (AP):In addition to prominent vascular tumor blush involving  the T7 vertebral body, there is also supply to the posterior left  spinal artery which fills cranially.
LEFT T8 (AP): Prominent tumor blush noted involving the T8 vertebral  body. In addition there is supply to the artery of Adamkiewicz.
LEFT T9 (AP): No tumor blush noted. No aneurysms or vascular  malformations.
RIGHT T9 (AP): No tumor blush, vascular malformations or aneurysms.
RIGHT T8 (AP): Faint tumor blush involving the T8 vertebral body noted. There is  no evident spinal arterial supply.
RIGHT T7 (AP): Faint tumor blush noted involving the right T7 vertebral body.  There is no evident spinal arterial supply.

IMPRESSION:
Endovascular embolization of the right T7 and T8 thoracic  intercostal arteries with particles and coils, as well as  embolization of the left T7 intercostal artery with a single coil. The left T8 intercostal artery is also associated with a prominent  tumor blush; however, this vessel was noted to supply the artery of  Adamkiewicz and was therefore not embolized.
Above findings were discussed with the Spine service immediately  after the procedure.
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VERTEBROPLASTY
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This patient is a participant of the INVEST study, a randomized study of vertebroplasty and as a result does not know if an actual vertebroplasty was performed. All persons reading this report should take care to prevent informing the patient about the information contained herein for one year following the date of this report.

HISTORY: L1 compression fracture.

EXAM: L1 vertebroplasty.

COMPARISON: MR lumbar spine 12/17/2007, plain radiographs of the
lumbar spine 12/17/2007.

TECHNIQUE: Written informed consent was obtained from the patient  following a lengthy discussion of the benefits and risks of the  procedure. All questions were answered. The consent was placed in  the patient's chart.

Following this, the patient was brought to the  angiography suite and placed prone upon the examination table. The  patient was prepped and draped in the usual sterile fashion.

The L1  vertebral level was identified and targeted using fluoroscopy. The  soft tissues above the left pedicle were anesthetized using lidocaine  via a 25G needle and subsequently a 22G spinal needle. With a  transpedicular approach, an 11 gauge needle was placed into the  lateral aspect of the vertebral body under fluoroscopic guidance with  position confirmed under lateral and frontal projections. This  entire procedure was repeated with the patient's right L1 pedicle.  Methymethacrylate was mixed and injected through both needles under  direct fluoroscopic visualization, eventually opacifying the  bilateral paracentral aspects of the vertebral body. Both needles  were removed. The patient tolerated the procedure well with no  immediate complications.   

I, Dr., the attending Neuroradiologist, was present  for all portions of the procedure.

FINDINGS:  L1 vertebral compression fracture with approximately 30% vertebral  height loss.  4 cc of methylmethacrylate mixed with barium was injected (2 cc  through each pedicle). The distribution of the cement was observed  under fluoroscopy. There is good bilateral distribution of cement.  A small amount of cement extravasation is seen into the prevertebral  soft tissues. Cement within the posterior aspect of the L1 vertebral  body also approximates but does not appear to enter the central canal.

IMPRESSION:
1. Successful fluoroscopic guided percutaneous vertebroplasty of the  L1 vertebral body without evidence of immediate complication.
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CT GUIDED SPINE BIOPSY
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EXAM: CT guided lumbar spine biopsy
HISTORY: Right frontoparietal brain mass with multiple spinal  and paraspinal masses including right L3 and L5 pedicles. Unknown  primary malignancy. COMPARISON: Lumbar spine MRI /2008  

TECHNIQUE: Informed consent was obtained from the patient's wife after  discussion of the risks, benefits and alternatives of the procedure.  The patient was able to consent himself due to altered mental  status/confusion.   The risks discussed included were limited to complications of  conscious sedation including respiratory depression, cardiovascular  collapse, as well as risks of the procedure including bleeding, infection, injury to nerves, vasculature, or adjacent organs, non diagnosis. The patient's wife wished to proceed and the signed  informed consent was placed in the chart.   

The patient was evaluated for conscious sedation prior to the  procedure by Dr. . Oxygenation and vital signs were continuously monitored. IV Versed  and Fentanyl were administered by the radiology nurse per order of  and under the direct supervision of Drs. .

Patient was placed prone on CT table. Axial 2.5mm sections were obtained w/o contrast from L1 to L5.  Skin over biopsy site was marked with CT guidance. Skin was then prepped and draped in sterile fashion. Adequate local anesthesia achieved with subcutaneous 1% lidocaine.   

Under intermittent CT guidance, a 16 G x 9 cm Tenmo needle biopsy  system was advanced into the L3 right paraspinal lesion and 2 core samples were obtained. A third pass was performed with a 16 G x 6 cm needle and a third core  sample was obtained. Needle was removed and hemostasis easily  achieved. No immediate complications. Samples were submitted to  pathology for analysis.   

I, Dr.  was present throughout the procedure.  

FINDINGS:   Pre biopsy images show a 2cm right paraspinal soft tissue mass centered at the right L3 level with bony involvement of the pedicle.

IMPRESSION: Successful CT guided biopsy of right L3 pedicle region paraspinal  mass without complication.