Diagnosis: Encephalopathy, unspecifiedClinical question: Encephalopathy The CSF spaces are appropriate for the patient's stated age with no midline shift. There is a mild degree of generalized brain atrophy present.No abnormal enhancing mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.There is redemonstration of a small cystic lesion just below the left cerebellar hemisphere measuring 16 x 6 mm in coronal dimensions which is stable when compared to the prior exam and most likely represents a small arachnoid cyst.Normal vascular flow voids are present in the distal carotid and vertebral arteries, the basilar artery and the proximal anterior, middle and posterior cerebral arteries as well as the internal cerebral veins and superior sagittal sinus.There is no evidence for any significant microhemorrhages in the brain parenchyma. There is no evidence for foci of diffusion restriction within the brain parenchyma.The visualized portions of the paranasal sinuses demonstrate opacification of the frontal sinuses, ethmoid air cells and sphenoids sinuses with an air-fluid level in the right maxillary sinus and mucosal thickening in the right maxillary sinus. There is a polypoid appearing lesion which extends into the right ostiomeatal complex unit from the right nasal cavity. This could also be identified on the prior exam from 7/12/2014. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact.
1.There is opacification of the paranasal sinuses with a polypoid type lesion in the right nasal cavity extending into the right maxillary sinus. Please correlate with clinical evaluation for nasal polyposis and/or possible antrochoanal polyp.2.An air-fluid level in the right maxillary sinus could potentially represent acute sinusitis. Please correlate with clinical symptoms3.Findings suggest a mild degree of generalized brain atrophy but not significantly different than the prior exam.4.Small arachnoid cyst adjacent to the left cerebellar hemisphere. This is stable.