Instruction: Generate impression based on findings.

Input: Male, 88 years old, with lower extremity weakness and a history of lumbar laminectomy, abscess. Posterior instrumented fusion has been performed from L4 through S1 with bilateral pedicle screws in place at these levels. An interbody fusion device is also been placed at L5-S1. Laminectomy has been performed at L4, L5 and at least partially at S1.A rim-enhancing fluid collection is evident within the superficial subcutaneous tissues of the operative region spanning from L3 through S1 and measuring 72 mm TV, 26 mm AP and 23 mm CC. This collection communicates via a thin tract with a deeper rim-enhancing fluid collection within the laminectomy bed which measures approximately 46 x 35 x 16 mm. This collection exerts minimal mass effect upon the thecal sac but causes no significant spinal canal stenosis.A grade 1 anterolisthesis of L5 relative to S1 is seen along with a mild exaggeration of the lumbar lordosis. Vertebral body heights are grossly preserved.Abnormal T2 hyperintense signal seen within the L3-4 intervertebral disc and the adjacent endplates. The endplates also show evidence of ill-defined enhancement. No associated paraspinal fluid collection is seen. However, the adjacent psoas muscles are edematous and enhancing.The visualized distal spinal cord and conus are within normal limits. No pathologic intrathecal enhancement is seen.L1-2: Minimal disc bulging. Right foraminal/far lateral annular fissuring and protrusion. No significant spinal canal stenosis. Mild bilateral foraminal narrowing. L2-3: Mild facet arthropathy and ligamentum flavum thickening. Mild bulging disc. Prominence of the dorsal epidural fat. Moderate effacement of the thecal sac with some crowding of the cauda equina. Moderate bilateral foraminal narrowing. L3-4: Facet arthropathy. Loss of disc height posteriorly is seen. In addition, there is a superiorly directed right paracentral extrusion measuring up to 16 mm in length which partially effaces the thecal sac. This, along with osseous distortion from surgery and thickening of the epidural soft tissues, contributes to a moderate generalized spinal canal stenosis with crowding of the cauda equina. The neural foramina are not well visualized but are likely significantly narrowed. L4-5: Facet arthropathy. Thickening of the residual ligamentum flavum. Disc bulging. Moderate generalized spinal canal narrowing. Moderate to severe foraminal narrowing. L5-S1: Facet arthropathy. Disc bulging. Mild generalized spinal canal narrowing. The neural foramina are not well assessed but may be mildly to moderately narrowed.

Output: 1.Postoperative findings are demonstrated compatible with posterior instrumented fusion from L4 through S1 and laminectomy as above.2.A rim-enhancing fluid collection is evident in the posterior soft tissues. This collection is composed of two components, one within the superficial subcutaneous space and the other located more deeply within the laminectomy bed. The two components communicate via a thin tract. These collections could represent postoperative seromas, but the possibility of infected collections is highly suspected.3.Disc and endplate signal abnormalities are seen centered at L3-4. In the context of associated inflammation of the adjacent anterior paraspinal soft tissues, these findings are concerning for discitis osteomyelitis.4.Multilevel degenerative findings are demonstrated. Most notably, at L3-4 there is a right paracentral superiorly directed disc extrusion. This, in combination with postoperative distortion and epidural thickening, contributes to at least a moderate generalized spinal canal stenosis.


Instruction: Generate impression based on findings.

Input: 52 year old female; rule out intracranial hemorrhage. No abscess identified.Patchy low attenuation in the subcortical white matter compatible with small vessel disease of indeterminate age.More focal low attenuation in the right high parietal region represents edema given subsequent contrast enhanced examination that revealed a metastatic focus at this location. This lesion is visible on the MRI dated 3/29/2008.There is no evidence of intracranial hemorrhage. The ventricles and basal cisterns are normal in size and configuration.The calvaria and skull base are radiographically normal. The visualized paranasal sinuses and mastoid air cells are normally pneumatized.

Output: 1. No intracranial hemorrhage.2. Metastatic lesion with surrounding edema in the high right parietal region adjacent to the cerebral falx; please see recent contrast enhanced examination for further details. If further workup is necessary, recommend MRI.


Instruction: Generate impression based on findings.

Input: Back pain, episode of bowel incontinence Vertebral body heights are maintained. Alignment is grossly maintained. Mild degenerative changes are present in the cervical, thoracic, and lumbar spine including small disc bulges in the cervical, thoracic, and lumbar spine. There is no significant compromise to the spinal canal or evidence of acute cord compression. Spinal cord signal is grossly unremarkable.

Output: This is a limited exam specific for the exclusion of cord compression only and does not exclude more subtle lesions such as intrinsic cord abnormalities. No evidence of spinal cord or cauda equina compression. Due to the screening nature of this protocol details are not as evident on imaging as dedicated protocols of the spine.


Instruction: Generate impression based on findings.

Input: Clinical question: Rule-out bleed versus ischemia. Signs and symptoms: Dizziness, syncope, intermittent blurry vision. CT of brain without infusion:No evidence of hemorrhage, edema, mass effect, midline shift or hydrocephalus is detected. No definitive evidence of small vessel disease on this non-infused CT of brain as it was noted on prior MRI examination.A small calcific density in the subcortical white matter of the left posterior frontal is noted (axial image 19). The finding may represent a small dystrophic calcification or a small cavernoma. Calvarium is unremarkable. Mastoid air cells and limited view of paranasal sinuses are unremarkable.

Output: Essentially unremarkable CT of brain without infusion. Please see above comments.


Instruction: Generate impression based on findings.

Input: 54-year-old female with left shoulder pain, posterior; possible rotator cuff tear. ROTATOR CUFF: There is increased signal intensity within the anterior fibers of the supraspinatus tendon at its insertion on the greater tuberosity indicating insertional tendinosis with cyst formation in the underlying bone. There is also increased signal intensity along the undersurface of the supraspinatus tendon likely representing fraying/degenerative tearing that is contiguous with additional intrasubstance degeneration more posteriorly in the tendon, but I see no fluid-filled full-thickness rotator cuff tear. There is perhaps mild fatty infiltration along the myotendinous junction of the supraspinatus, but the muscle otherwise appears normal. There is also mild fatty infiltration along the myotendinous junction of the infraspinatus, but the infraspinatus muscle and tendon otherwise appear normal. The teres minor muscle and tendon appear normal. There is mild insertional tendinosis of the subscapularis, but otherwise the muscle and tendon appear normal. A couple of small lobular foci of fluid signal intensity are noted along the superficial margin of the subscapularis tendon, perhaps representing small ganglia.SUPRASPINATUS OUTLET: There is an os acromiale, a normal variant. Mild osteoarthritis affects the acromioclavicular joint. There is trace fluid in the subacromial/subdeltoid bursa, of questionable significance.GLENOHUMERAL JOINT AND GLENOID LABRUM: Glenohumeral joint alignment is within normal limits, and there is no joint effusion. Given the limitations of a non-arthrogram study, I see no labral tear. There is perhaps minimal degeneration of the articular cartilage of the glenohumeral joint.BICEPS TENDON: Given the limitations of a non-arthrogram study, the tendon of long head of the biceps appears normal.

Output: 1.Tendinosis and undersurface fraying/degenerative tearing of the supraspinatus, without a full-thickness fluid-filled tear. Other findings as described above.


Instruction: Generate impression based on findings.

Input: 50 years, Male, Reason: Hx of common bile duct dilation on MRCP, CBD stricture, chronic pancreatitis, jaundice, ascending cholangitis History: Jaundice. ABDOMEN:LUNG BASES: No significant abnormality notedLIVER, BILIARY TRACT: There is a focal T2 hyperintense lesion in the left hepatic lobe which is not seen on T1 precontrast or postcontrast sequences, possibly a cyst but findings nonspecific/of uncertain clinical significance. No suspicious hepatic lesion evident otherwise. Loss of signal on out of phase images suggest diffuse hepatic steatosis.Mild irregularity and narrowing of the proximal intrahepatic bile ducts. The common bile duct appears normal without dilatation or stenosis.SPLEEN: No significant abnormality noted.PANCREAS: Normal-appearing pancreatic duct. Previously seen pancreatic stent is not visualized, possibly removed. No evidence of pancreatic divisum. Normal parenchymal signal without focal lesion evident.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: 1.4-cm right renal hemorrhagic cyst. Simple 1.2-cm left renal cyst.RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted.

Output: 1.Mild narrowing of the proximal intrahepatic bile ducts without dilatation. Common bile duct itself is normal without evidence of stricture.2.No evidence of cholangitis as clinically questioned.3.No findings of chronic pancreatitis.


Instruction: Generate impression based on findings.

Input: Meningioma, repeat 6 month follow up: evaluate for changes/growth. There is no significant interval change in size of the extra-axial enhancing left lateral skull base mass centered along the left petrous apex with extension into the cavernous sinus, left prepontine cistern, and along the left tentorial leaflet. There is also associated hyperostosis and permeation of tumor into the underlying skull. There is encasement of the left cavernous carotid artery, which is mildly narrowed. There is persistent mass effect with vasogenic edema in the left temporal lobe. There is also mass effect upon the left brainstem. There is no evidence of acute intracranial hemorrhage or acute infarction. The ventricles are unchanged in size and configuration. There is no significant midline shift. There is staphylomatous deformity of the bilateral globes. There is mild high T2 signal within the left mastoid air cells suggestive of fluid or mucosal thickening. There appears to be filler material within the bilateral nasolabial folds. There are unchanged patchy T1 hyperintense areas in the left parietal skull.

Output: No significant interval change in size of the left petroclival meningioma with extension into the cavernous sinus, left prepontine cistern, and along the left tentorial leaflet, and permeation of tumor into the underlying skull, as well as encasement and narrowing of the left cavernous carotid artery. Associated vasogenic edema in the left temporal lobe persists. I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.


Instruction: Generate impression based on findings.

Input: Pain. There are 4 lumbar type vertebral bodies. Alignment is anatomic. Disc spaces are well preserved.

Output: Normal radiographs of the lumbar spine.


Instruction: Generate impression based on findings.

Input: Neck pain with radicular pain, clumsiness, and signs of myelopathy. Craniovertebral junction appears within normal limits. The cervical vertebral bodies are appropriate in height. Cervical lordosis is maintained. There is minimal retrolisthesis of C4 on C5 and C5 on C6. Bone marrow signal is benign with small focus of T1 hyperintensity involving the C4 vertebral body compatible with focus of fat or small hemangioma.The cervical spinal cord has normal signal characteristics and overall morphology.Degenerative changes are seen in the cervical spine as described below:C2-3: No significant compromise to the spinal canal or right neural foramen. Left-sided facet arthropathy with associated mild left neural foraminal stenosis.C3-4: Small central disc protrusion. No significant compromise to the spinal canal. There is mild right neural foraminal stenosis related to mild uncovertebral hypertrophy and facet arthropathy. Left neural foramen is patent. Bilateral facet arthropathy, worse on the left.C4-5: Small disc osteophyte complex and ligamentum flavum thickening with minimal narrowing of the spinal canal at this level. There is mild to moderate right and minimal left neural neural foraminal narrowing.C5-6: Disc osteophyte complex and ligamentum flavum thickening contribute to mild to moderate degree of spinal canal stenosis. There is mild bilateral neural foraminal stenosis. C6-7: Small disc osteophyte complex and ligamentum flavum thickening with mild spinal canal stenosis. There is mild to moderate left and mild right neural foraminal stenosis. C7-T1: No significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact. Paraspinous soft tissue structures appear within normal limits. There is a 5 mm nodule along the medial aspect of the inferior right thyroid lobe.

Output: 1. Degenerative changes in the cervical spine, worst at the C5-C6 level where there is mild to moderate degree of spinal canal stenosis. No cord signal abnormality. There is also mild spinal canal stenosis present at C6-C7 and minimal at C4-C5. 2. Multilevel neural foraminal stenoses as above.


Instruction: Generate impression based on findings.

Input: Per EPIC, patient with multiple recurrent GBM status post resection (11/18/11), RT/TMZ (completed 12/11/12) and explored alternative therapies until there was tumor growth in 01/2013. He then started TMZ and received 6 cycles (completed 09/13). With additional tumor growth, he enrolled in a Phase II randomized ReACT Trial and received bevacizumab +/- rindopepimut. He received 4 cycles and there was radiographic progression (MRI 04/14/14). He shortly thereafter developed symptomatic intracranial hemorrhage,and would not allow him to move forward with potential therapy on the DCVax Trial at Cedars-Sinai for which he underwent a craniotomy (06/17/14) with preliminary pathology from the biopsy revealing exclusively necrosis. Final pathology revealed viable tumor, however. He then resumed treatment on the ReACT Trial but without the bevacizumab because of the hemorrhage. He then developed rapid clinical and radiographic progression (MRI 09/09/14). He then underwent a craniotomy with extensive tumor resection (09/22/14). Now on everolimus+Optune. Evaluate for growth. There are post-operative findings related to right sided craniotomy. There is interval increase in size of the heterogenously enhancing mass within the right sided resection bed measuring 9.1 x 5.9 x 6.6 cm (AP x TR x CC), previously 7.4 x 3.7 x 6.0 cm. There are increased areas of necrosis posteriorly. On perfusion imaging, there is elevated relative cerebral blood volume within the majority of the enhancing tissue. There is increased local mass effect with effacement of the right lateral ventricle and increased right to left midline shift measuring 1.4 cm, previously 0.9 cm. There is minimal enlargement of the left lateral ventricle, which may be entrapped. There is mild right uncal herniation. There are multiple foci of susceptibility effect and residual foci of T1 hyperintensity, compatible with old blood products. There is diffusion restriction at the posterior aspect of the tumor, which may indicate areas of hypercellular tumor. There is increased T2 hyperintensity throughout the right cerebral white matter and corpus callosum as well as the right thalamus. Increased T2 hyperintensity in the right cerebral peduncle and right medullary pyramid, likely represents direct tumor spread with superimposed Wallerian degeneration. The major cerebral flow voids are intact. There is unchanged minimal punctate non-specific enhancement within the left internal auditory canal.

Output: Post-operative findings related to right-sided craniotomy with interval increase in size of the heterogenously enhancing mass, increased T2 hyperintense signal, local mass effect and increased right to left midline shift measuring 1.4 cm, compatible with continued tumor progression. Mild right uncal herniation. Minimal enlargement of the left lateral ventricle, which may be entrapped.


Instruction: Generate impression based on findings.

Input: 32-year-old female with new onset hematuria, ultrasound findings concerning for defect in the uterus and thickening of the bladder wall. PELVIS:UTERUS, ADNEXA: Intrauterine pregnancy is present with a posteriorly positioned placenta. No evidence of placenta previa. Fetal presentation is cephalic. Fat plane is present between region of lower uterine segment and dome of the bladder.BLADDER: Bladder is collapsed and within normal limits. There is no significant surrounding free fluid in the pelvis. There is no intraluminal signal void to suggest gas within the bladder.LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: There is mild right greater than left hydronephrosis, favored to be physiologic given patient's gravid state.

Output: 1.Within limitations of an underdistended bladder, no fistulous connection between the uterus and bladder is evident as clinically queried. No significant free fluid in the pelvis.2.Please note that this nondedicated exam does not constitute formal evaluation of fetal anatomy.


Instruction: Generate impression based on findings.

Input: Clinical question:? Disk herniation. Signs and symptoms: Back pain and sciatica. Nonenhanced lumbar MRI:Lower most visualized thoracic spine and thoracic cord is unremarkable.T12 -- L1 is unremarkableL1 -- L2 demonstrate moderate disk disease and loss of disk height and mild degenerative changes of the posterior elements without central spinal stenosis or neural MR compromiseL2 -- L3 demonstrate mild disk disease and loss of disk height and mild bilateral ligamentum flavum hypertrophy and mild facet disease. No spinal stenosis or neural foraminal compromiseL3 -- L4 demonstrate moderate disk disease and loss of disk height, moderate ligamentum flavum hypertrophy and mild facet disease. Constellation of changes results in moderate central spinal stenosis and mild right neural foraminal compromise.L4 -- L5 demonstrate advanced disk disease and loss of disk height, mild grade 1 anterolisthesis, moderate bilateral ligamentum flavum hypertrophy (right greater than left), facet disease and with images of widening of the facet spaces demonstrating T2 hyperintensity (facet effusion or inflammatory change). Constellation of changes result in moderate to severe central spinal stenosis and moderate to severe bilateral neural foraminal compromise.L5 -- S1 demonstrate moderate to severe disk degeneration and loss of disk height, moderate symmetrical bilateral ligamentum flavum hypertrophy and mild facet disease. No spinal stenosis however a mild to moderate bilateral neural foraminal compromise is detected.Limited view of the SI joints demonstrate no abnormalities.Perispinal soft tissues and musculature remains unremarkable.

Output: 1.Extensive degenerative changes at L4 -- L5 and including mild grade 1 anterolisthesis results in significant central spinal stenosis and moderate to severe neural foraminal compromise.2.Degenerative changes at L3 -- L4 results in moderate central spinal stenosis and mild right neural foraminal compromise.3.Degenerative changes at the L5 -- S1 with resultant mild to moderate bilateral neural foraminal compromise and no central spinal stenosis.4.Mild degenerative changes at other levels however without spinal stenosis or significant neuroforaminal compromise. Please see detailed report per level above.


Instruction: Generate impression based on findings.

Input: Reason: endometriosis, adhesions, bowel lesions noted on laparoscopy History: pelvic pain, dysmenorrhea.Additional history per electronic medical record: On laparoscopy, multiple areas of endometriosis, both classic black powder burn and clear lesions noted. Approximately 4 cm adhesion of bowel and omentum to the right abdominal wall. The right ovary was noted to have an endometrioma. PELVIS:UTERUS, ADNEXA: In the region of the right adnexa, there is a rounded structure which appears to arise from the right ovary which measures 2.0 x 2.3 cm (series 501, image 35) which demonstrates intrinsically increased T1 signal with associated T2 shading and is compatible with an endometrioma or hemorrhagic cyst. The remaining portions of the right ovary demonstrate normal-appearing follicles. There are multiple additional round structures within the left adnexa which demonstrates intermediate T2 signal and possible fluid fluid levels which are compatible with additional hemorrhagic cysts and/or endometriomas. In total, the right adnexa measures approximately 2.2 x 3.3 cm. The left adnexa measures approximately 2.5 x 4.5 cm.The uterus is retroverted and anteflexed in position and measures approximately 5.8 x 4.5 x 7.8 cm. Several round foci of decreased T2 signal within the myometrium are compatible with fibroids. There is no specific evidence of adenomyosis. Normal variant nabothian cysts are noted.BLADDER: No significant abnormality noted.LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: A loop of small bowel is present immediately adjacent to the right adnexa with possible slight bowel thickening and which may be adherent to the right adnexa. No evidence of obstruction currently within the partially visualized portions of bowel.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted.

Output: Multiple adnexal structures as described above which may reflect endometriomas and/or hemorrhagic cysts. Recommend correlation with prior ultrasound and/or subsequent ultrasound in 4-6 weeks, as persistence would favor endometriomas. No large/visible bowel implants are identified. Possible bowel adhesion to the right adnexa.


Instruction: Generate impression based on findings.

Input: 87 years Male (DOB: 5/21/1929)Reason: dizziness and falls History: fallsPROVIDER NAME: CHRISTOPHER L KRAMER MRI brain:The CSF spaces are appropriate for the patient's stated age with no midline shift. There is generalized brain atrophy present.There is an 11 mm lesion in the right frontal lobe which on all pulse sequences has a peripheral area of low signal in the popcorn-like appearance centrally on T2 and T1 imaging. It is predominantly bright centrally on T1 and T2.On susceptibility imaging there are several punctate foci of signal loss in the cerebellar hemispheres. Additional punctate foci of signal loss on susceptibility imaging are present in the right periventricular white matter as well as the right half of the corpus callosum at the level of the splenium.There is a subgaleal hematoma present adjacent the right parietal bone measuring 11 mm in thickness. There is no evidence for coup or contrecoup injury.No abnormal mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.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.The visualized portions of the paranasal sinuses are clear. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact.MRI cervical spine:The cervical vertebral bodies are appropriate in overall height. The cervical spinal cord has normal signal characteristics and overall morphology. No abnormal lesions are identified in the cervical spine. There is straightening of the normal cervical curvature present.At C2-3 there is no significant compromise to the spinal canal or neural foramina. There is bilateral facet hypertrophy present at this levelAt C3-4 there is no significant compromise to the spinal canal or neural foramina. There is bilateral facet hypertrophy present at this level. There is mild anterior subluxation of C3 on C4.At C4-5 there is no significant compromise to the spinal canal or neural foramina. There is bilateral facet hypertrophy present at this level associated with uncovertebral osteophytes and mild anterior subluxation of C4 and C5At C5-6 there are endplate uncovertebral osteophytes present associated loss of disc space height and some encroachment of the left-sided exiting nerve roots within the neural foramina.At C6-7 there is no significant compromise to the spinal canal or neural foramina. Endplate osteophytes are present at this level.At C7-T1 there is no significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact.

Output: 1.Right frontal lobe cerebral cavernous malformation.2.Multilevel degenerative changes are present cervical spine associated with neural foramen encroachment of exiting nerve roots bilaterally at C3-4 and on the left-sided C5-6. There is mild anterior subluxation of C4 on C5 and C3 on C4


Instruction: Generate impression based on findings.

Input: Dizziness for 9 years. There is no evidence of intracranial hemorrhage, mass, or acute infarct. There are scattered foci of high T2 signal in the cerebral white matter and patchy T2 hyperintensity in the pons. The cerebellum appears unremarkable. The inner ear structures and internal auditory canal appear grossly unremarkable. There is no abnormal intracranial enhancement. The ventricles and basal cisterns are normal in size and configuration. There is no midline shift or herniation. The major cerebral flow voids are intact. The orbits are grossly unremarkable. There is extensive mucosal thickening in the right maxillary sinus, where there are also secretions. There is also diffuse mucosal thickening in the ethmoid and left maxillary sinuses.

Output: 1. No evidence of intracranial hemorrhage, mass, or acute infarct. 2. Scattered foci of high T2 signal in the cerebral white matter and patchy T2 hyperintensity in the pons are nonspecific, but may represent chronic small vessel ischemic disease. 3. The inner ear structures and internal auditory canal appear grossly unremarkable. 4. Findings suggestive of sinusitis.


Instruction: Generate impression based on findings.

Input: History of brain tumor. Evaluate change. CT of brain without and with contrast:Examination again demonstrates heavily calcified and partially cystic multi-loculated mass in bilateral lateral ventricles. The mass is inseparable from the choroid plexus of the lateral ventricle and is believed to arise from the choroid plexus. On post infusion images there is no enhancement of this mass. The mass is larger in the right lateral ventricle and extends from the trigone of right lateral ventricle and into the body of right lateral ventricle. There is no evidence of hydrocephalus associated with this finding. In comparison with the prior examination there is no definitive evidence of increase in the size of this tumor or any change in its density characteristics. The measurements are minimally smaller than prior study however this could be secondary to slice positioning.Previously described increased signal intensity in the periventricular white matter and corpus callosum (edema) on MRI examination of brain cannot be identified on this CT study.This examination is otherwise unremarkable and also stable.90 cc of Omnipaque 350 was utilized for the study.

Output: 1.Calcified, cystic and multi-loculated mass in the lateral ventricles bilaterally with no enhancement or interval change since prior study.2.Differentials for this tumor include xanthogranuloma, great plexus carcinoma, lymphoma or metastatic lesion.


Instruction: Generate impression based on findings.

Input: The ventricles and sulci are normal in size. The cerebellar tonsils are in normal position. There are no masses, mass effect or midline shift. The pituitary gland is normal in size. There is no evidence for intracranial hemorrhage or acute cerebral, brainstem or cerebellar infarction. No diffusion-weighted abnormalities are identified. There are no extraaxial fluid collections or subdural hematomas. Flow voids are present within the major vessels indicating patency. There are scattered sporadic foci of mucosal thickening within the sinuses. The mastoid air cells are clear.Coronal images of the temporal lobes demonstrate the temporal horns, hippocampal formations and parahippocampal gyri to be normal in size and symmetric bilaterally without signal abnormalities or masses identified within the medial temporal lobes on either side. There is no evidence of mesial temporal sclerosis and there are no foci of heterotopic gray matter.

Output: Negative MRI of the brain. Specifically, there are no MRI findings to explain the patient's seizures.


Instruction: Generate impression based on findings.

Input: 19 years Male (DOB:1/1/1997)Reason: sickle cell anemia, history of Moya Moya History: surveillancePROVIDER/ATTENDING NAME: ELIZABETH M DRUMM ELIZABETH M DRUMM MRI of the brainNo diffusion weighted abnormalities are appreciated.The CSF spaces are appropriate for the patient's stated age with no midline shift. There are multiple punctate T2 and FLAIR hyperintense foci between the anterior and middle cerebral artery territories within the subcortical and periventricular white matter. These were also present on the prior exam. These are stable compared to the prior exam.No significant perfusion delay is hypoperfusion is appreciated in the anterior cerebral artery territories are the posterior cerebral artery territoriesNo abnormal mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.Normal vascular flow voids are present in the distal carotid and vertebral arteries, the basilar artery and the proximal middle and posterior cerebral arteries as well as the internal cerebral veins and superior sagittal sinus.The visualized portions of the paranasal sinuses are clear. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact.MRA brain:The current MR angiogram was performed on a 1.5 Tesla MRI unit with a low spatial resolution whereas the prior MR angiogram was performed on a 3 Tesla magnet with a high spatial resolution. There is significant difference in spatial resolution between the 2 studies.Antegrade flow is present in the distal internal carotid arteries, the distal vertebral arteries, the basilar artery and the proximal middle and posterior cerebral arteries.The A1 segments are occluded at their origin and reconstituted distally.There is a stenosis present at the left posterior cerebral artery at the proximal P2 segment.There is no evidence for intracranial aneurysm or cerebrovascular occlusion.The right posterior communicating arteries is medium-sized. The left posterior communicating artery is very small. The left vertebral artery is larger than the right vertebral artery.

Output: 1.There is occlusion of the anterior cerebral artery A1 segments proximally with distal reconstitution. This was also identified on the prior exam. Please note that there are spatial resolution limitations on the current exam which were not present on the prior exam making assessment for interval change slightly less reliable.2.There is a stenosis suspected of the left posterior cerebral artery at the proximal P2 segment was not present on the prior exam3.There is no hypoperfusion on the basis of perfusion exam..4.Punctate lesions in the watershed zones between the anterior middle cerebral artery territories are stable and most likely related to ischemia.


Instruction: Generate impression based on findings.

Input: 31-year-old man with seizure yesterday. Known seizure history. Fell with trauma and contusion to left eye. There is no evidence of intracranial hemorrhage, mass or edema. Right temporal encephalomalacia is present with ex vacuo dilatation of the trigone of the right lateral ventricle -- this finding has been previously evaluated with MRI and is stable. The ventricles and basal cisterns are otherwise normal in size and configuration.Findings of left orbit trauma are partially visualized including blowout fracture of the lamina papyracea with herniation of orbital fat into the left ethmoid air cells, thickening of the medial rectus muscle, and orbital emphysema. The visualized paranasal sinuses and mastoid air cells are otherwise normally pneumatized.

Output: 1. Partially visualized findings of the left orbit trauma including medial wall fracture. If clinically appropriate, consider dedicated orbital CT.2. No CT findings of intracranial traumatic injury.


Instruction: Generate impression based on findings.

Input: 70-year-old female with obstructive jaundice and cholecystitis. History of prior gastric bypass and hemicolectomy. Evaluate for CBD stone and determine anatomy. ABDOMEN:LIVER, BILIARY TRACT: Dilated common bile duct with a small intrahepatic stone measuring 4.8 mm in craniocaudal length and 3.8 mm in transverse diameter (coronal series 9 image 84), which is unlikely to be the source of extra hepatic biliary ductal dilatation as flow is seen along the lateral margins. A small stone at the ampulla cannot be excluded. Mild central intrahepatic biliary ductal dilatation. Few scattered hepatic cysts.Distended gallbladder containing small gallstones in the dependent fundus. No pericholecystic fluid identified. No obstructing stones identified in the cystic duct.SPLEEN: No significant abnormality noted.PANCREAS: No pancreatic mass. Mild pancreatic ductal dilatation.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: Left kidney with significant parenchymal atrophy measuring 8.5 cm in length, and a small simple cyst of the left lower renal pole is noted. There is compensatory hypertrophy of the right kidney measuring 12.1 cm in length. In the anterior right upper pole, there is a 2.5 cm cyst (axial series 6 image 34) with a fluid fluid level (axial series 8 image 30 suggesting a hemorrhagic cyst. In the posterior right upper renal pole, there is a 3.3 cm cyst, and smaller scattered renal cysts are also noted on the right.RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: Status post right hemicolectomy. Findings compatible with history of gastric bypass including focal dilatation of a left upper quadrant small bowel bowel loop.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted.

Output: 1.Choledocholithiasis with a 4.8 x 3.8 mm stone in the distal common bile duct, however this is unlikely to be a flow-limiting obstruction. A smaller stone at the ampulla or recently passed stone cannot be excluded. No periampullary mass identified. Mild central intrahepatic ductal dilatation and mild pancreatic ductal dilatation also noted. 2.Distended gallbladder with gallstones in the dependent gallbladder fundus. No obstructing stone in the cystic duct.3.Parenchymal atrophy of the left kidney with compensatory hypertrophy of the right kidney. Right renal cysts are noted, including a 2.5 cm suspected hemorrhagic cyst of the right upper pole.


Instruction: Generate impression based on findings.

Input: Syncope, neurologic deficits, and difficulty performing calculations. Possible prior TIA. MRI brain:No foci of restricted diffusion to indicate acute ischemia. Scattered foci of periventricular and subcortical white matter increased T2 signal are compatible with chronic small vessel ischemic disease which is stable to minimally progressed compared to prior. Small area of focal encephalomalacia in the posterior right frontal lobe compatible with a chronic infarct. There are a few scattered foci of susceptibility in the posterior fossa compatible with prior microhemorrhages.There is no evidence of intracranial mass or edema. Stable prominence of the CSF spaces in the posterior fossa which may be related to mega cisterna magna or small arachnoid cyst. The ventricles and basal cisterns are normal in size and configuration. The expected intracranial vascular flow voids are present.Mild mucosal thickening involving the paranasal sinuses. Partial opacification of the left mastoid air cells. MRA head and neck:No significant stenotic disease in the neck. Conventional arch anatomy. The carotid and right vertebral artery origins are widely patent. The origin of the left vertebral artery is poorly visualized, likely due to artifact as the vessel immediately develops a normal caliber. No evidence of dissection.Intracranial carotid arteries are also widely patent. Minimal atherosclerotic changes are seen without significant stenosis in the anterior or posterior circulation. Diminutive/absent bilateral PCOM arteries. Codominant vertebrobasilar system. No intracranial aneurysms.

Output: 1. No evidence of acute infarct.2. Mild to moderate chronic small vessel ischemic changes are stable to minimally progressed compared to prior from 2012.3. No significant stenosis in the intracranial vasculature or extracranial vasculature in the neck.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.


Instruction: Generate impression based on findings.

Input: The ventricles, sulci and cisterns are symmetric and unremarkable. The gray-white matter differentiation is normal. There is no mass, midline shift, intra or extra-axial fluid collection/hemorrhage, restricted diffusion/acute ischemia, or abnormal contrast enhancement. The midline structures and cranial-cervical junction are normal. Normal flow voids are identified in the major intracranial vessels. The paranasal sinuses and mastoid air cells are not opacified.

Output: No acute intracranial abnormality.


Instruction: Generate impression based on findings.

Input: 53 years Male (DOB:8/29/1962)Reason: metastatic lung CA, followup to eval for brain mets History: nonePROVIDER/ATTENDING NAME: PHILIP C. HOFFMAN PHILIP C. HOFFMAN The CSF spaces are appropriate for the patient's stated age with no midline shift. There are is a FLAIR and T2 and diffusion-weighted imaging signal hyperintense focus in the right choroid plexus and the smaller one in the left choroid plexus. Most likely these represent xanthogranulomas.There is a 34 x 23 mm axial dimension cystic lesion in the anterior aspect of the left middle cranial fossa associated with remodeling of the adjacent bone. It follows spinal fluid on all pulse sequences.There are several periventricular and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images. These are probably of little clinical significance. There are unchanged compared to the prior exam.No abnormal enhancing mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma. 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 intracranial origin of the left posterior inferior cerebellar artery.The visualized portions of the paranasal sinuses are clear. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact.

Output: 1.There is no evidence for brain metastasis appreciated. 2.Arachnoid cyst in the left middle cranial fossa.3.Choroid plexus lesions most likely represent xanthogranulomas.


Instruction: Generate impression based on findings.

Input: Multiple sclerosis: numbness, headaches. There are multiple, greater than 10, scattered cerebral white mater T2 hyperintense lesions bilaterally, predominantly in a periventricular distribution. Many of the lesions also display low T1 signal, but there is no abnormal intracranial enhancement. There is also a T2 hyperintense lesion in the right cerebellar hemisphere and within the spinal cord at the C3-4 level. The findings appear to be similar in extent as in 2015. There is no evidence of intracranial hemorrhage, mass, or acute infarct. The ventricles and basal cisterns are normal in size and configuration. There is no midline shift or herniation. The major cerebral flow voids are intact. The orbits, skull, and scalp soft tissues are grossly unremarkable. There is mild mucosal thickening in the bilateral maxillary sinuses.

Output: Findings compatible with intracranial demyelinating lesions related to multiple sclerosis. A lesion in the cervical spinal cord also likely represents a demyelinating lesions related to multiple sclerosis. These findings are similar in extent as in 2015.


Instruction: Generate impression based on findings.

Input: Female, 57 years old, with cavernoma. A lobular hemosiderin stained lesion is redemonstrated in the left anterior temporal lobe centered on the temporal horn of the lateral ventricle. The lesion contains heterogeneous T2 internal signal as well as intrinsically T1 bright signal, some of which may have diminished relative to the prior examination. The overall area of signal abnormality on T2-weighted images measures up to 3 cm in diameter. No definite associated developmental venous anomaly is seen. No other parenchymal lesions are detected. Ventricular size and morphology remain within normal limits. A few scattered nonspecific foci of T2 hyperintensity are demonstrated within the cerebral white matter. An incidental arachnoid cyst is suspected along the right anterior temporal lobe.

Output: A lesion is present in the left anterior temporal lobe showing features consistent with a cavernous malformation. No definite associated developmental venous anomaly is seen.


Instruction: Generate impression based on findings.

Input: 41-year-old female presents with right knee pain. MENISCI: There is globular intermediate signal in the anterior horn of the lateral meniscus extending to the body with an associated parameniscal cyst. Intermediate density within the posterior horn of the medial and lateral meniscus with extension to the inferior articular surface.ARTICULAR CARTILAGE AND BONE: Generalized thinning of the articular service of the lateral femoral condyle but no focal cartilage defects are identified. There is heterogeneity of the articular cartilage of the patellofemoral joint. No abnormal bone marrow signal intensity.LIGAMENTS: The ligaments of the knee are intact. EXTENSOR MECHANISM: The extensor mechanism is intact.ADDITIONAL

Output: Tears involving the medial and lateral menisci with an associated parameniscal cyst.


Instruction: Generate impression based on findings.

Input: BRAIN: There is extensive T2 signal abnormality in the supratentorial brain predominantly (greater than 15 lesions with extensive confluent lesions), and scattered T2 lesions in the posterior fossa. Compared to the prior exam, there is mild to moderate interval increase of extensive confluent T2 hyperintense signal abnormality in the periventricular supratentorial brain. There are a few posterior fossa lesions redemonstrated and minimal in the bilateral cerebellar hemispheres. There is mild new ring enhancement of a right periventricular white matter lesion suggesting active demyelination. There is mild prominence of the ventricles representing global volume loss, unchanged.PITUITARY: There is a hypoenhancing lesion in the right pituitary gland measuring up to 7 mm without significant change. There is no mass effect on the optic apparatus or significant extension into the adjacent cavernous sinus. The infundibulum remains deviated to the left. There is increased asymmetric enhancement in the right cavernous sinus as compared to the left, also unchanged.

Output: 1.Mild to moderate interval worsening of confluent T2 signal abnormality in the supratentorial brain consistent with demyelination given history of multiple sclerosis. An old T2 hyperintense lesion in the right periventricular white matter shows new enhancement consistent with active demyelination.2.Stable 7-mm hypoenhancing right pituitary lesion perhaps representing a microadenoma.


Instruction: Generate impression based on findings.

Input: Check for OCD. Right ankle sprain localized to lateral aspects A small focal 4 mm lucency is observed along the medial aspect of the talar dome, concerning for an OCD. MRI may be needed to confirm and properly evaluate. Superimposed mild degenerative changes are otherwise identified most pronounced along the lateral aspects and lateral malleolus. In light of the patient's history and overlying diffuse mild to moderate swelling greater on the lateral aspects, ligamentous injury is most likely.The Achilles and remaining visualized osseous structures are otherwise intact

Output: Degenerative changes and possible talar dome OCD is observed. See recommendation provided


Instruction: Generate impression based on findings.

Input: 59 year old man with history of non-ischemic cardiomyopathy, paroxysmal atrial fibrillation and syncope with no inducible VT/SVT on EP study, referred for cardiac MRI. Left VentricleThe left ventricle is moderately-severely dilated with normal systolic function. The LV is dilated even after adjusting for BSA; however, normal ranges are not at all well defined in individuals of his height. The overall LV ejection fraction is 56%, the LV end diastolic volume index is 130 ml/m2 (normal range: 74+/-15), the LVEDV is 319 ml (normal range 142+/-34), the LV end systolic volume index is 58 ml/m2 (normal range 25+/-9), the LVESV is 141 ml (normal range 47+/-19), the LV mass index is 32 g/m2 (normal range 85+/-15), and the LV mass is 78 g (normal range 164+/-36). There are no regional wall motion abnormalities present. There is a transmural area of late gadolinium enhancement in the basal inferolateral wall which is unlikely to represent myocardial infarction because it is within a region of myocardium that has normal wall thickness. The finding suggests the presence of an underlying fibrosing, infiltrative, or inflammatory process. There is no evidence of myocardial iron overload. Left AtriumThe left atrium is moderately enlarged. The interatrial septum appears aneurysmal.Right VentricleThe right ventricle is moderately dilated with normal systolic function. The RV is dilated even after adjusting for BSA; however, normal ranges are not at all well defined in individuals of his height. The overall RV ejection fraction is 57%, the RV end diastolic volume index is 136 ml/m2 (normal range 82+/-16), the RVEDV is 332 ml (normal range 142+/-31), the RV end systolic volume index is 59 ml/m2 (normal range 31+/-9), and the RVESV is 144 ml (normal range 54+/-17). While the indexed diastolic volume is elevated, there are no regional wall motion abnormalities of the right ventricle to suggest underlying ARVC.Right AtriumThe right atrium is moderately dilated.Aortic ValveThe aortic valve opens widely and there is no significant aortic regurgitation.Mitral ValveThe mitral valve opens widely and there is trivial mitral regurgitation.Pulmonic ValveThe pulmonic valve opens widely. There is no significant pulmonic regurgitation.Tricuspid ValveThe tricuspid valve opens widely. There is no significant tricuspid regurgitation.AortaThere is a left sided aortic arch with a normal brachiocephalic branching pattern. The aortic root is normal in size. Normal origin of the coronary arteries. Pulmonary VeinsAll four pulmonary veins drain normally into the left atrium.Pulmonary ArteryThe main pulmonary artery is normal in size.Venous AnatomyThe SVC and IVC are normal in size and drain normally into the right atrium.PericardiumThere is a trivial pericardial effusion.Extracardiac FindingsThis study is not designed for the specific evaluation of extra-cardiac findings; therefore, the differentiation between artifacts and real extracardiac pathology may be difficult. If clinically indicated, a separate dedicated evaluation should be considered.

Output: 1. Moderate-severely dilated left ventricle with normal systolic function (EF 56%). The LV is dilated even after adjusting for BSA; however, normal ranges are not at all well defined in individuals of his height. 2. There is a small transmural area of late gadolinium enhancement in the basal inferolateral wall which is unlikely to represent myocardial infarction because it is within a region of myocardium that has normal wall thickness. The finding suggests the presence of an underlying fibrosing, infiltrative, or inflammatory process.3. Moderately dilated right ventricle with normal systolic function (EF 57%) and no regional wall motion abnormalities. The RV is dilated even after adjusting for BSA; however, normal ranges are not at all well defined in individuals of his height. 4. Biatrial dilation. 5. Aneurysmal interatrial septum. 6. Normal origin of the coronary arteries. I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.


Instruction: Generate impression based on findings.

Input: 28 year old female with history of Crohn's disease, perianal disease status post end ileostomy with parastomal abscess. Evaluate for small bowel disease or fistulous connection to abscess. PELVIS:UTERUS, ADNEXA: No significant abnormality noted.BLADDER: No significant abnormality noted.LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: Again seen are bilateral, complex perianal transsphincteric tracts with one tract beginning at the left 5 o'clock position (series 41/35) and another beginning at the right 10 o'clock position (series 41/31) with both crossing and connecting at the posterior midline (coronal series 501/42). Both complex tracts demonstrate blind-ending bilateral superior extension, similar to prior exam. There is inferior extension of the right tract located subcutaneously in the right medial gluteal cleft and extending to the skin surface, similar to prior exam. There is blind-ending inferior extension of the left tract in the left ischioanal fossa. There has been mild interval increased size of the right-sided tract as it extends posteriorly and crosses the midline (series 401/37) and in the inferior extension in the left ischioanal fossa (sagittal series 601/26).Right lower quadrant ileostomy stoma with a minimal amount of fluid signal in the subcutaneous portion of the stoma, but no specific evidence of abscess.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted.

Output: Multiple bilateral, complex perianal fistulous tracts with mild interval increased size as detailed above.


Instruction: Generate impression based on findings.

Input: Pain and weakness following ulnar nerve transposition Exam limited secondary to absent prior comparison imaging as well as extensive postsurgical findings including punctate blooming artifact throughout the area in question. Within this limitation the following observations are made including focal signal abnormality in the overlying medial epicondyles with a small bone spur (circled). Overlying postsurgical scarring and soft tissue changes are observed yet the expected released ulnar nerve is seen more anteriorly in a continuous fashion. Minimal signal is identified proximally yet specifically no abnormal enhancement, deformity or displacement. No discrete MR findings to suggest fascial bands, abnormal soft tissue, cysts or ganglia are identified. No synovitis. The ulnar collateral ligament and retinaculum are intact.Non-specific mild signal in the medial head of the triceps preventing exclusion of possible denervation. Please correlate with patient presentation given the appearance yet inconsistency with relayed history.

Output: Medial epicondylar spur, see detail and pertinent negatives provided.


Instruction: Generate impression based on findings.

Input: 16 year-old male. Pain, instability. Evaluate for ACL tear. MENISCI: The lateral and medial menisci are normal in signal intensity and morphology without evidence of a tear.ARTICULAR CARTILAGE AND BONE: ACL osseus avulsion fracture of the medial tibial tubercle with surrounding edema type signal in the intercondylar eminence extending into the medial and lateral tibial plateau consistent with bone contusion.Small impaction fracture of the subchondral bone in the lateral femoral condyle with an articular cortical step-off of 3 mm (series 701, image 23). There is adjacent edema type signal in the lateral femoral condyle consistent with bone contusion. Tibiofemoral and patellofemoral compartment cartilage is intact.LIGAMENTS: The ACL is completely avulsed from its tibial insertion with a small attached bone fragment comprised of the medial tibial tubercle. Mild retraction of the ACL, which is diffusely high in signal. High PCL, MCL, and LCL are intact.EXTENSOR MECHANISM: No significant abnormality noted.ADDITIONAL

Output: 1. ACL avulsion fracture from the tibial intercondylar eminence.2. Small impaction fracture of the lateral femoral condyle with a 3 mm articular step-off.3. Bone contusions in the tibial intercondylar eminence extending into the medial and lateral tibial plateau.


Instruction: Generate impression based on findings.

Input: The risks (including, but not limited to, those of bleeding, infection, allergic reaction, temporary nerve block, pain, and inability to access the joint) and benefits of the procedure were explained to the patient, and informed written consent was obtained. A pre-procedural “time-out” form was completed.The patient was placed supine on the fluoroscopy table. The left hip was localized fluoroscopically, and a spot radiograph was obtained. The course of the femoral artery was noted on the patient's skin using an ink marker. The skin was cleansed and covered with a sterile drape. The skin and subcutaneous tissues were anesthetized with 1% lidocaine using 25-gauge and 22-gauge needles.Under fluoroscopic guidance, a 20-gauge spinal needle was advanced into the joint. Attempted aspiration yielded no fluid. Next, 10 ml of a 50/50 mixture of Omnipaque 240 (to confirm the intra-articular position of the needle) and dilute Multihance (0.1 cc in a 10 cc vial of saline, for subsequent MR imaging) were injected into the joint. Contrast opacified the joint in the expected manner. A spot radiograph was obtained for documentation. Subsequently, 40 mg (1 cc) of Kenalog was injected into the left hip joint. The needle was withdrawn. Blood loss was negligible (<1cc), and patient tolerated the procedure well without immediate complication. Routine post procedure instructions were communicated to the patient. The patient was escorted to the MRI suite for further imaging in stable condition. Please refer to the subsequent MRI report for further information.Exposure time: 0:43

Output: Successful intra-articular injection of contrast material for a left hip MRI arthrogram, and successful intra-articular steroid injection.


Instruction: Generate impression based on findings.

Input: CHF admitted with ADHF requiring inotropes, reported recent stroke at OSH. There is no evidence of acute intracranial hemorrhage, mass, or acute infarct. There is mild diffuse cerebral volume loss. There are a few scattered, punctate foci of susceptibility effect in the cerebral white matter, which may represent chronic microhemorrhages. There is mild diffuse, primarily periventricular white matter T2 hyperintensity. There are small areas of encephalomalacia in the right inferior cerebellar hemisphere and right paracentral lobule. There is no abnormal intracranial enhancement. There is no midline shift or herniation. The major cerebral flow voids are intact. The orbits, skull, paranasal sinuses, and scalp soft tissues are grossly unremarkable. There is degenerative spondylosis in the imaged upper cervical spine, which is otherwise incompletely characterized.

Output: 1. No evidence of acute intracranial hemorrhage, mass, or acute infarct. 2. Probable chronic small vessel ischemic white matter disease and small chronic right cerebellar hemisphere and right paracentral lobule infarcts.3. Mild diffuse cerebral volume loss.4. Degenerative spondylosis in the imaged upper cervical spine, which is otherwise incompletely characterized.


Instruction: Generate impression based on findings.

Input: 34-year-old female with history of a pancreatic lesion on CT. Patient with nausea and vomiting. Evaluate pancreatic lesion. ABDOMEN:LIVER, BILIARY TRACT: Segment 8 and 4A subcentimeter T1 hypointense, T2 hyperintense lesions demonstrate no contrast enhancement; findings compatible with cysts.SPLEEN: No significant abnormality noted.PANCREAS: The hypoattenuating 9 mm focus that was noted on the CT examination in the pancreatic head corresponds to interdigitating fat. No evidence of a lesion within the pancreas.ADRENAL GLANDS: No significant abnormality noted.KIDNEYS, URETERS: No significant abnormality noted.RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: Small hiatal hernia.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted.

Output: 1.Previously noted subcentimeter pancreatic head lesion corresponds to interdigitating fat.2.Two subcentimeter hepatic cysts.


Instruction: Generate impression based on findings.

Input: The ventricles and sulci are normal in size and configuration for the patient's age. The basal cisterns remain patent. There is no midline shift or mass effect. There are numerous foci of abnormal T2/FLAIR hyperintensity within the periventricular and subcortical white matter, consistent with moderate chronic small vessel ischemic changes. There are a few punctate foci of susceptibility artifact within the right cerebral hemisphere. There is no diffusion abnormality. No extra-axial fluid collection is identified.Normal flow-voids are demonstrated in the major intracranial vascular structures. The midline structures and craniocervical junction are within normal limits. There is near complete opacification of the left maxillary sinus and bilateral ethmoid air cells. Moderate mucosal thickening is present within the right frontal sinus and right maxillary sinus. No air fluid levels are appreciated.

Output: 1.No acute abnormality. 2.Numerous scattered foci of FLAIR hyperintensity are statistically most likely to represent chronic small vessel ischemic disease.3.There are a few scattered foci of susceptibility artifact within the right cerebral hemisphere. These usually indicate chronic microhemorrhage which can be seen in amyloid but also with hypertensive/microvascular hemorrhages and in the setting of prior head trauma.4.Extensive mucosal thickening in the paranasal sinuses as described above.


Instruction: Generate impression based on findings.

Input: 63-year-old male with pain. Evaluate rotator cuff. ROTATOR CUFF: There is thickening and intermediate signal intensity within the supraspinatus and infraspinatus tendons indicating moderate tendinosis. There is also high signal intensity within the supraspinatus tendon at its insertion on the greater tuberosity representing a concealed interstitial tear, measuring approximately 1 cm in AP dimension, which involves approximately 1/3 to 1/2 of the tendon. There is also increased signal intensity at the insertion of the infraspinatus tendon more posteriorly which may represent additional insertional tearing without evidence of retraction. There may also be mild bursal surface fraying of the supraspinatus tendon. There is mild fatty atrophy along the myotendinous junction of the infraspinatus muscle but the supraspinatus and infraspinatus otherwise are normal in appearance. The teres minor and subscapularis tendons and muscles appear normal.SUPRASPINATUS OUTLET: Mild to moderate osteoarthritis affects the acromioclavicular joint with osteophyte formation and capsular hypertrophy resulting in mild impression upon the superior fibers of the supraspinatus tendon. There is a trace amount of fluid within the subacromial/subdeltoid bursa. There is minimal increased signal intensity within the bursa on fluid sensitive sequences which may reflect mild inflammation.GLENOHUMERAL JOINT AND GLENOID LABRUM: Moderate osteoarthritis affects the glenohumeral joint with scattered foci of signal abnormality within the labrum likely representing degeneration/degenerative tearing. There is linear signal abnormality partially separating the anterior labrum from the glenoid along with slight flattening of the lateral aspect of the humeral head which raises the possibility of prior anterior dislocation. There is a small amount of fluid within the joint but no large effusion is evident.BICEPS TENDON: There is thickening and increased signal intensity within the long head of the biceps tendon at its transition from the rotator cuff interval to the intertubercular groove, indicating moderate tendinosis. The tendon of the long head of the biceps is also perched upon the superior aspect of the lesser tuberosity which may represent a pulley lesion. There is fluid within the biceps tendon sheath which may represent mild tenosynovitis. There is a subcentimeter ovoid focus of intermediate signal intensity within the biceps tendon sheath which may represent a cartilage fragment.

Output: 1. Supraspinatus and infraspinatus tendinosis with insertional (likely concealed) tearing without evidence of retraction as described above.2. Acromioclavicular and glenohumeral joint osteoarthritis.3. Moderate tendinosis and tenosynovitis of the long head of the biceps tendon and other findings as described above.


Instruction: Generate impression based on findings.

Input: History of MEN IIa syndrome. Adrenal tumors, likely pheochromocytoma. History of left adrenalectomy in 2007 showed pheochromocytoma. ABDOMEN:LIVER, BILIARY TRACT: The liver is normal in morphology and signal intensity. No focal suspicious lesion. No biliary ductal dilatation. The vessels are patent.SPLEEN: No significant abnormality noted.PANCREAS: No significant abnormality noted.ADRENAL GLANDS: There is nodularity of the right adrenal gland, appearing similar to the prior study. The dominant nodules measures 9 and 6 mm.Status post left adrenalectomy.KIDNEYS, URETERS: Bilateral renal cortical thinning with underlying calyceal blunting compatible with reflux nephropathy, unchanged. RETROPERITONEUM, LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted.PELVIS:UTERUS, ADNEXA: No significant abnormality noted.BLADDER: No significant abnormality noted.LYMPH NODES: No significant abnormality noted.BOWEL, MESENTERY: No significant abnormality noted.BONES, SOFT TISSUES: No significant abnormality noted.OTHER: No significant abnormality noted.

Output: 1.Stable mild nodularity of the right adrenal gland may reflect discrete adrenal nodules, too small to accurately characterize, or nodular adrenal hyperplasia. Correlate with urine metanephrine to exclude pheochromocytomas. No new sites of disease.2.Changes of reflux nephropathy bilaterally are unchanged.


Instruction: Generate impression based on findings.

Input: 25 year-old woman with history of left knee pain and catching. MENISCI: The medial and lateral menisci are intact.ARTICULAR CARTILAGE AND BONE: The tibiofemoral and patellofemoral compartment articular cartilage is intact. Cortical and bone marrow is normal.LIGAMENTS: The ACL, PCL, MCL, and LCL complex are intact. EXTENSOR MECHANISM: The extensor mechanism is intact.ADDITIONAL

Output: No finding to explain the patient's pain.


Instruction: Generate impression based on findings.

Input: Evaluate for infiltrative or neoplastic process. Left upper extremity weakness. Abnormal finding on Head CT. There is apparent diffuse enlargement of the brainstem with loss of the delineation of especially the inferior margin of the belly of the pons. There is mild T2 FLAIR hyperintensity within the central pons, accentuating hypointense transverse pontine fibers. FLAIR/T2 hyperintensity is also identified within the expanded and convex midbrain bilaterally. The cerebellar tonsils are normal in morphology, low normal in position. However, there is crowding of the foramen magnum. There is prominent near complete effacement of the prepontine cistern.There is no evidence of intracranial hemorrhage or acute infarct. There is a single punctate focus of T2/FLAIR intensity in the right frontal subcortical white matter. There is no abnormal intracranial enhancement. The ventricles are normal in size and configuration. There is no midline shift or herniation. The major cerebral flow voids are intact.

Output: Diffuse symmetric expansion of the brainstem, particularly of the pons, with areas of T2 hyperintensity within the central pons and midbrain, concerning for an infiltrative process such as brainstem glioma. Differential diagnosis could include demyelinating disease and osmotic demyelination, if clinically applicable.Findings were discussed with Dr. Paul Kukulski, ER resident, at 11:30am on 10/21/16.


Instruction: Generate impression based on findings.

Input: Left tail of parotid pleomorphic adenoma. There is a well-defined, slightly lobulated, T2 hyperintense, enhancing mas in the tail of the left parotid gland, which measures up to 25 mm. There is no ductal dilatation and the other salivary glands are unremarkable. There is no significant lymphadenopathy in the neck. There is a posterior right nasopharyngeal mucous retention cyst that measures up to 12 mm. There is prominence of the bilateral palatine tonsils. The thyroid gland is unremarkable. The osseous structures are intact. The imaged portions of the orbits and intracranial structures are unremarkable.

Output: 1. A left parotid mass that measures up to 25 mm is compatible with pleomorphic adenoma. 2. Nonspecific prominence of the bilateral palatine tonsils.


Instruction: Generate impression based on findings.

Input: Reason: History of medulloblastoma treated with surgery, chemotherapy, and radiotherapy, has cochlear implant that is MRI compatible to 1.5 tesla. See note from 8/13/2015 Emmanuel J Villegas, A.P.N. for instructions History: yearly follow up There is again extensive susceptibility artifact from a right cochlear implant, obscuring large parts of the right posterior head/intracranial structures. This includes the cerebellar treatment bed at midline in the posterior fossa. There is minimal central nodular enhancement along the inferior cerebellum as seen on 12/34, which appears similar if not slightly less conspicuous when compared to prior exams. Minimal linear enhancement is seen along the right anterior aspect of the overlying fluid collection, presumably relating to granulation tissue. Otherwise, the visualized brain demonstrates no abnormal contrast enhancement. T2/FLAIR hyperintense gliosis is again seen along the left paramedian frontal lobe with adjacent chronic lacunar infarct in the corona radiata the left. Ventricles and sulci remain prominent, consistent with moderate global volume loss greater than expected for patient's stated age. Diffusion weighted imaging is essentially nondiagnostic. There is no midline shift or mass effect. There is a persistent small extracranial CSF signal intensity collection along the suboccipital craniectomy site, consistent with a pseudomeningocele. This measures 1.7 cm AP x 7.1 cm CC, not significantly changed.

Output: 1. Limited exam secondary to extensive susceptibility artifact from right-sided cochlear implant. Incomplete visualization of the surgical bed in the posterior fossa, although no definite suspicious enhancement identified to suggest tumor recurrence.2. Grossly stable appearance of presumed pseudomeningocele overlying the craniectomy site


Instruction: Generate impression based on findings.

Input: 89 years Female (DOB:12/14/1926)Reason: r/o malignancy, stroke History: clinical appearance of seizures, likely renal malignancyPROVIDER/ATTENDING NAME: MICHELLE K MARTINCHEK MICHELLE K MARTINCHEK There are patchy foci of diffusion restriction present along the left cingulate gyrus and left corpus callosum anteriorly. Additional patchy foci of diffusion restriction are present along the left superior frontal gyrus posteriorly and the left paracentral lobule. In general there is no significant mass effect associated with this is only a relatively small portion of the anterior cerebral artery territories involved. These are also hyperintense on T2 and FLAIR MRI.A punctate focus of T2 and FLAIR signal hyperintensities present in the left thalamus. Some scattered foci of T2 and FLAIR signal hyperintensity are present in the brainstem.There are multiple punctate foci of loss of signal on susceptibility weighted image imaging is scattered throughout the subcortical white matter but also in the right basal ganglia, left thalamus and brainstem.There is a moderate degree of periventricular and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images.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. The distal left anterior cerebral artery flow void is loss at approximately the level of the genu of the corpus callosum (a3 segment)The visualized portions of the paranasal sinuses are clear. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact. The eyeball lenses are thin.

Output: 1.Patchy and small to medium sized subacute cerebral infarction the territory of the left anterior cerebral artery. There is no significant mass effect associated with it.2.Periventricular and subcortical white matter lesions of a moderate degree are nonspecific. At this age they are most likely vascular related. 3.Multiple microhemorrhages are present within the brain parenchyma. Differential considerations include hypertension, amyloid angiopathy or both.


Instruction: Generate impression based on findings.

Input: 71 year old male with history of fall with neck pain. Please evaluate. There is no evidence of intracranial hemorrhage, mass or edema. The ventricles and basal cisterns are normal in size and configuration.The calvaria and skull base are radiographically normal. The visualized paranasal sinuses and mastoid air cells are normally pneumatized.There is grade I retrolisthesis of C5 on C6 of approximately 5 mm that appears unchanged from the prior MRI 3/3/2009. In addition, there are destructive changes of the endplates at C5-C6 that is also unchanged; these findings are compatible with a chronic, non-progressive destructive process.Disk bulge noted at C3-C4; unchanged from previous MRI.No acute fracture. The remainder of the spine is in normal alignment.

Output: 1. Stable destructive process at C5-C6; there are no findings to suggest acute or progressive process.2. No acute intracranial abnormality.


Instruction: Generate impression based on findings.

Input: Primary hypothyroidism.EXAMINATION: Sonogram thyroid 02/08/16 RIGHT LOBE MEASUREMENTS: 0.8 x 0.5 x 1.3 cmLEFT LOBE MEASUREMENTS: 0.8 x 0.4 x 0.8 cmISTHMUS MEASUREMENTS: 0.1 cmRIGHT LOBE: No significant abnormality noted.LEFT LOBE: No significant abnormality noted.ISTHMUS: No significant abnormality noted.PARATHYROID GLANDS: Not identifiedLYMPH NODES: Multiple small normal-appearing lymph nodes are seen.OTHER: No significant abnormality noted.

Output: Normal appearance of the thyroid. Multiple lymph nodes.


Instruction: Generate impression based on findings.

Input: L sided weakness/numbness and headache, patient is 28 weeks pregnant MRI brain: No intracranial abnormal diffusion restriction. No acute intracranial hemorrhage is identified. No evidence of intracranial mass, mass-effect, or midline shift. No extra-axial fluid collections. The ventricles, sulci, and cisterns are normal in size without evidence of hydrocephalus. Gray-white matter differentiation is preserved. The imaged paranasal sinuses and mastoid air cells are clear. The imaged orbits are intact. The osseous structures are unremarkable. Scattered subcutaneous lymph nodes noted. MRV brain: There is normal venous flow demonstrated within the internal cerebral veins, vein of Galen, straight sinus, and superior sagittal sinus. The right transverse and sigmoid sinuses are diminished in caliber compared to the developmentally dominant left. No definite dural venous sinus thromboses or occlusions are identified.

Output: 1. Normal examination of the brain. 2. Unremarkable MRV of the head.


Instruction: Generate impression based on findings.

Input: Right knee pain. Decreased range of motion.IMAGE ACQUISITIONS: Nonenhanced CT of the right knee There are tiny osteophytes and small cysts in the tibial plateau indicating mild osteoarthritis. A tiny, 3 mm, density projects just above the central aspect of the tibial plateau and could conceivably represent a loose body but more likely represents a small focus of calcification in the distal fibers of the anterior cruciate ligament. Please note, the integrity of the menisci and ligaments can be better assessed with MRI but the posterior cruciate ligament is well seen and appears intact. The collateral ligaments likewise appear grossly intact. The anterior cruciate ligament is largely indistinct but we cannot ascertain if this is abnormal on this study. The extensor mechanism is intact. There is a small amount of fluid within the semimembranosus/gastrocnemius bursa (Baker's cyst).

Output: Mild degenerative changes as described above. If further imaging evaluation is clinically warranted, MRI can be considered.


Instruction: Generate impression based on findings.

Input: 63-year-old male with painful mass and localized swelling on the dorsal aspect of the right small finger metacarpophalangeal joint for 6 weeks. There is a mass within the soft tissues dorsal to the fifth metacarpal head. The mass insinuates between the extensor tendons of the fifth finger. The tendons appear normal.The mass is fluid signal intensity, showing only peripheral enhancement following gadolinium administration. There is little if any edema in the adjacent soft tissues and we see no frank destruction of the underlying bone.There appears to be very mild synovitis of the underlying fifth metacarpophalangeal joint, with small focus of abnormal subchondral signal intensity in the fifth metacarpal head. On the large field of view coronal images, rounded foci of signal abnormality are also seen within the second, third, and fourth metacarpal heads with narrowing of the second metacarpophalangeal joint associated with mild synovitis.The radial collateral ligament of the fifth metacarpophalangeal joint is indistinct and thickened, which may reflect a sprain or tear. Radial collateral ligament of the second metacarpophalangeal joint is also likewise indistinct and may be torn.

Output: 1.Peripherally enhancing mass of fluid signal intensity dorsal to the fifth metacarpal head, which may represent a ganglion or perhaps a synovial lined fluid collection. The relative absence of adjacent soft tissue edema argues against abscess.2.Other findings as above.


Instruction: Generate impression based on findings.

Input: 22 year old with Ehlers Danlos Syndrome and shortness of breath. Patient referred to evaluate aorta and LV size/ function. Left VentricleThe left ventricle is normal in size and systolic function (LVEF 60-65% qualitatively). There is no late gadolinium enhancement to suggest the presence of an underlying fibrosing, infiltrative, or inflammatory process.Left AtriumThe left atrium is normal in size. Right VentricleThe right ventricle is normal in size and systolic functionRight AtriumThe right atrium is normal in size.Aortic ValveThe aortic valve opens widely and there is no significant aortic regurgitation.Mitral ValveThe mitral valve opens widely and there is no significant mitral regurgitation.Pulmonic ValveThe pulmonic valve opens widely. There is no significant pulmonic regurgitation.Tricuspid ValveThe tricuspid valve opens widely. There is no significant tricuspid regurgitation.AortaThere is a left sided aortic arch with a normal brachiocephalic branching pattern. No evidence of thoracic or abdominal (up to infra-renal aorta) aortic aneurysm or dissection. Aortic dimensions are:Sinus of Valsalva: 27x27x27mmSinotubular Junction: 22x24mmAscending Aorta: 22x23mmMid Aortic Arch: 21x22mmDescending Aorta: 17x17mmPulmonary VeinsAll four pulmonary veins drain normally into the left atrium.Pulmonary ArteryThe main pulmonary artery is normal in size.Venous AnatomyThe SVC and IVC are normal in size and drain normally into the right atrium.PericardiumThere is no obvious pericardial disease.Extracardiac FindingsThis study is not designed for the specific evaluation of extra-cardiac findings; therefore, the differentiation between artifacts and real extracardiac pathology may be difficult. If clinically indicated, a separate dedicated evaluation should be considered.

Output: 1. No evidence of aortic aneurysm or dissection.2. Normal left ventricular size and systolic function (LVEF 60-65% qualitatively) without evidence of underlying myocardial fibrosis, inflammation, or infiltration.3. Normal right ventricular size and systolic function.Quantification software unavailable. Report to follow with addendum that includes quantitative measurements of left and right ventricle.


Instruction: Generate impression based on findings.

Input: Yearly follow for lumbar syrinx. There is absence of posterior elements in the L4-L5 spine and sacrum, consistent with spinal dysraphism. There is partial fusion of the L3 and L4 vertebrae, consistent with segmentation anomaly. There is unchanged exaggerated lordosis of the lumbar spine and kyphosis of the thoracic spine, as well as mild rotatory scoliotic deformity. There is an unchanged low lying conus medullaris that terminates at the L3 level associated with an elongated morphology of the spinal cord, which contains long-segment syringohydromyelia that measures up to 2 mm in width. There is an ectatic thecal sac in the lumbosacral region, which contains nerve roots and a portion of the conus that herniate through the dysraphism into the posterior soft tissues of the lower back consistent with myelomeningocele. There are unchanged foci of T2 hypointensity and T1 hyperintensity in the region of the conus, which may represent residual postoperative blood products. There is anterior lumbosacral lipomatosis. There is no significant spinal canal stenosis. The paraspinal soft tissues are unchanged. There is partly imaged left hip joint dislocation and effusion.

Output: 1. Unchanged appearance of the spinal dysraphism with myelomeningocele with tethered cord configuration and syringohydromyelia.2. Partly imaged left hip joint dislocation and effusion.


Instruction: Generate impression based on findings.

Input: 50 year old with known bilateral breast cysts. History of benign right breast biopsy. Personal history of liposarcoma of the right thigh. History of breast cancer in mother, two maternal aunts and maternal grandmother. No current breast complaints. Three standard views of both breasts were performed digitally and reviewed with the aid of R2 CAD, 9.3. The breast parenchyma is heterogeneously dense, unchanged in pattern and distribution. A marker clip in the right lower inner quadrant is unchanged in position. Stable partially obscured masses are present in both breasts, corresponding to cysts seen on previous MRI and ultrasound examinations. Scattered benign calcifications are present. No new masses, suspicious microcalcifications or areas of architectural distortion are present in either breast.

Output: No mammographic evidence of malignancy. As long as the patient's physical examination remains unremarkable, bilateral diagnostic mammogram is recommended annually. Results and recommendations were discussed with the patient. BIRADS: 2 - Benign finding.RECOMMENDATION: ND - Diagnostic Mammogram.


Instruction: Generate impression based on findings.

Input: Reason: assess for medial meniscal injury History: knee pain for 10 months. MENISCI: The medial and lateral menisci are intact without discrete tears.ARTICULAR CARTILAGE AND BONE: The articular cartilage is intact without focal defects. No bone marrow edema. Glenohumeral joint alignment is normal.LIGAMENTS: The cruciate and collateral ligaments are intact. EXTENSOR MECHANISM: The extensor mechanism is intact.ADDITIONAL

Output: Normal examination with no specific findings to account for the patient's pain.


Instruction: Generate impression based on findings.

Input: Reason: internal derangement History: pain MENISCI: There is a complex tear of the posterior horn of the medial meniscus which extends to involve the body of the meniscus. There is globular increased signal abnormality within the posterior horn of the lateral meniscus, near its root, indicating intrasubstance degeneration. Some of the signal extends to the articular surface indicating degenerative tearing.ARTICULAR CARTILAGE AND BONE: There is subjective thinning of the articular cartilage of the medial compartment and patellofemoral compartment. There is full-thickness articular cartilage degeneration along the medial aspect of the medial tibial plateau with underlying subchondral cyst formation and signal abnormality which is likely degenerative in etiology. There is also full-thickness articular cartilage degeneration along the lateral aspect of the lateral tibial plateau with underlying subchondral signal abnormality which is likely degenerative in etiology. There are tricompartmental osteophytes.LIGAMENTS: The cruciate and collateral ligaments appear intact. There is thickening and intermediate signal intensity within the ACL with associated lobulated foci of fluid signal intensity internally indicating mucoid degeneration.EXTENSOR MECHANISM: The extensor mechanism appears intact.ADDITIONAL

Output: 1. Complex tear of the medial meniscus and degenerative tearing of the lateral meniscus.2. Osteoarthritis of the knee including full-thickness articular cartilage degeneration most pronounced along the medial and lateral tibiofemoral compartments. Other findings as described above.


Instruction: Generate impression based on findings.

Input: Ms.Maria Weber, 70 year old, submitted outside studies for review. She had a left breast cancer status post excisional biopsy with multiple positive margins and a re-excision.Images performed at Vassar Brothers Medical Center submitted for review: Mammogram 12/15/2015MRI breasts 12/21/2015Images submitted for comparison:MRI breast 4/16/2015Mammogram 2/12/2015 and priors MAMMOGRAM: Three standard views of both breasts were obtained. The breast parenchyma is heterogeneously dense, unchanged in pattern and distribution. Linear markers are placed on the scar overlying the both breasts and right axilla. There are stable new lumpectomy changes present in the left breast, including architectural distortion, increased density, and surgical clips. Benign calcifications are present bilaterally. No dominant mass, suspicious microcalcifications or areas of architectural distortion are noted in either breast. MRI breast:Multisequence MRI breast imaging with and without intravenous contrast was performed as per outside MRI breast protocol. The breasts are composed of heterogeneous fibroglandular tissue. There is minimal background parenchymal enhancement bilaterally. There are postsurgical changes, including surgical clips and small seroma, in the posterior left breast, approximately 10:00 position. Susceptibility artifacts and scars are also present in the anterior right breast, approximately 2:00 position. There is no suspicious mass or masslike enhancement in either breast, including the left breast surgical bed. Axillary lymph nodes are unremarkable.

Output: No suspicious findings on mammogram or breast MRI. Expected postsurgical changes in the posterior left breast.BIRADS: 2 - Benign finding.RECOMMENDATION: X - No Letter.


Instruction: Generate impression based on findings.

Input: Splenium lesion seen before monitoring: speech issues, ESRD, and treated pseudotumor cerebri. There has been interval resolution of the abnormal T2 hyperintense focus in the splenium of the corpus callosum. The rest of the brain parenchymal signal is unremarkable. There is mild diffuse prominence of the sulci and ventricles, which appears to be new since the prior MRI. There is no evidence of intracranial hemorrhage, mass, or acute infarct. There is no midline shift or herniation. The major cerebral flow voids are intact. There is diffuse thickening and hypointensity of the skull. The orbits now appear unremarkable with resolution of prominent subarachnoid spaces in the optic nerve sheaths.

Output: 1. Interval of the signal abnormality in the splenium of the corpus callosum, which is compatible with transient splenial hyperintensity. 2. Interval resolution of prominent subarachnoid spaces in the optic nerve sheaths related to prior pseudotumor cerebri. Likewise, interval mild diffuse prominence of the sulci and ventricles may be related to treatment effects.3. Diffuse thickening and hypointensity of the skull may be related to renal osteodystrophy.


Instruction: Generate impression based on findings.

Input: Altered mental status. Ischemic stroke on CT scan. The study is limited by patient motion.There is a relatively large area of diffusion restriction involving the left frontal, temporal, and parietal lobes as well as the lateral aspect of the basal ganglia. This is associated with mild swelling closing the respective sulci and mildly compressing the left lateral ventricle associated with minimal midline shift but no brain herniation. Along the superior edge of the acute infarct, there are foci of susceptibility effect and minimal cortical contrast enhancement. This infarct is associated with apparent loss of the flow void in the left M1 segment and attenuation of the left MCA sylvian branches. However, this study is not optimized for arterial assessment.Right parietal encephalomalacia from chronic infarct as well as moderate-to-severe chronic microvascular ischemia of the cerebral white-matter remain unchanged since the previous CT scan. Encephalomalacia also involves the posteromedial aspect of the cerebellar hemispheres, deep to the suboccipital craniectomy. Mild brain volume loss has not changed also. Orbits are notable for changes of bilateral eye lens replacement. There is trace mucosal thickening in the ethmoid sinuses.

Output: 1.Examination is limited by patient motion.2.Fairly large acute left MCA territory infarct with foci of petechial hemorrhage along its superior margin but no discrete hematoma to suggest frank hemorrhagic conversion. Mild local mass effect associated with the infarct.3.Right parietal chronic infarct, moderate-to-severe chronic microvascular ischemia of the cerebral white-matter and mild brain volume loss remain unchanged.4.Suboccipital craniectomy with underlying cerebellar encephalomalacia are also unchanged.I personally reviewed the Images and/or procedure with the Resident/Fellow and agree with this report.


Instruction: Generate impression based on findings.

Input: Evaluate for spinal stenosis. There is a normal lumbar lordosis. The lumbar spine alignment and the vertebral body height appear normal. T12/L1, L1/L2, L2/L3: unremarkable. L3/L4: mild disc bulge; no neuroforaminal compromise or spinal canal stenosis. L4/L5: disc bulge; bilateral facet joint and ligamentum flavum hypertrophy; bilateral facet joint space widening with fluid accumulation on the right and air accumulation on the left; bilateral neuroforaminal compromise; spinal canal stenosis (8 mm in AP). L5/S1: mild disc bulge; no neuroforaminal compromise or spinal canal stenosis. Incidental findings are atrophy of bilateral kidneys and heavy calcification in the abdominal aortic and iliac arteries.

Output: Degenerative disease of the lumbar spine, most pronounced at L4/L5, as detailed above.


Instruction: Generate impression based on findings.

Input: 40-year-old male with swelling of wrist and fingers. There is reticulation of the subcutaneous fat of the dorsum of the hand and wrist, also extending along the ulnar aspect of the hand and wrist where it becomes confluent. Edema also extends into the bases of the fourth and fifth fingers. We see no abscess. There is however fluid within the tendon sheath of the extensor digitorum tendons, as well as synovial enhancement indicating tenosynovitis at the level of the wrist and proximal metacarpals. We see no findings to suggest osteomyelitis. There is mild enhancement surrounding the proximal interphalangeal joint of the middle finger, suggesting inflammation. We see no substantial joint effusion.

Output: Soft tissue inflammation and extensor digitorum tenosynovitis.


Instruction: Generate impression based on findings.

Input: Images are motion degraded. Given this caveat:There are tiny punctate foci of restricted diffusion with matching ADC hypointensity within bilateral cerebellar hemispheres as well as supratentorial brain, most notable involving the right parietal lobe and posterior right frontal lobe.Hemorrhagic products are noted within the patient's shunt tract as well as within the known falcine comment bilateral occipital horn, and left cerebellar hemorrhages.Confluent T2 hyperintensity is present within the white matter as well as pons without associated restricted diffusion, susceptibility abnormality, or enhancement. Chronic lacunar infarcts are noted involving bilateral thalami.Note is again made of left occipital lobe encephalomalacia. The cerebellar tonsils are in normal position. The pituitary gland is normal in size. There are no extraaxial fluid collections or subdural hematomas. Flow voids are present within the major vessels indicating patency. There is no abnormal enhancement within the brain.

Output: 1.The study is motion degraded limiting sensitivity of the study.2.There are tiny punctate foci of restricted diffusion with matching ADC hypointensity within bilateral cerebellar hemispheres as well as supratentorial brain, most notable involving the right parietal lobe and posterior right frontal lobe. Given the vascular distribution, these most likely represent an embolic origin.3.Redemonstration of intracranial hemorrhages.4.Advanced chronic small vessel ischemic disease.5.Left occipital lobe encephalomalacia.


Instruction: Generate impression based on findings.

Input: Progression of ataxia, cerebellar atrophy. Revaluate left frontal and DWI lesion, and question of multiple possible cavernoma There is no restricted diffusion to suggest acute ischemia. There are multiple T2 hyperintense lesions throughout the periventricular and subcortical white matter. Relatively largest of these is seen in the left frontal lobe involving the posterior aspect of the left superior frontal gyrus. There are tiny foci of susceptibility within this lesion suggestive of microhemorrhages. There is diffusion hyperintensity with increased ADC. There is mild associated enhancement.There is a 9-mm intraparenchymal focus of susceptibility effect involving the right parietal lobe with additional susceptibility effect in the adjacent intraparietal sulcus indicative of prior subarachnoid component of the hemorrhage. There is mild enhancement associated with the intraparenchymal focus. Mild associated mineralization better seen on prior CT. Additional foci of susceptibility are also seen in the right parietal lobe involving the cuneus as well as along the cortex of the right temporo-parieto-occipital junction.There is severe volume loss involving the cerebellum including the cerebellar hemispheres and vermis as well as the pons, midbrain, and bilateral middle cerebellar peduncles.Sella and orbits are grossly within normal limits. Paranasal sinuses and mastoid cells are clear. Bone marrow signal and extracranial soft tissues are within normal limits.

Output: 1. No evidence of acute ischemia, intracranial mass, or mass effect.2. Multiple foci of chronic microhemorrhage in the right parietal and occipital lobes, as described above. Favored differential is amyloid angiopathy. Multiple cavernous malformations is also a possibility although appearance is not typical. Relatively largest of these lesions measures 9 mm in the right parietal lobe and associated with evidence of prior subarachnoid hemorrhage including hemosiderin deposition along the right intraparietal sulcus. There is mild associated enhancement as well. 3. Multiple foci of FLAIR hyperintensity in the subcortical and periventricular white matter. These may be related to chronic small vessel ischemic disease but are nonspecific. There are tiny foci of hemorrhage associate with the left frontal lesion with increased diffusivity and enhancement. Subacute ischemia remains a possibility although amyloid angiopathy, again can be considered, with possible inflammatory component. Other vasculitides can also be considered although the visualized vessels on recent CTA were normal in caliber. Patient age and presence of hemorrhage within the left frontal lesion makes demyelinating disease much less likely.4. Cerebellar and brainstem volume loss compatible with diagnosis of spinocerebellar ataxia.


Instruction: Generate impression based on findings.

Input: History of aneurysm, 6 mo follow-up. History of right MCA stroke and thrombectomy on Jun 8 2012 Brain MRI:No evidence of acute ischemia. Again seen is FLAIR hyperintensity and volume loss involving the right frontal, parietal, and temporal lobes as well as the posterior insula consistent with prior right MCA infarct. Small infarcts involving the right frontal corona radiata and anterior caudate also again seen. Mild FLAIR hyperintensity involving the bilateral periventricular white matter is compatible with chronic small vessel ischemic changes. Chronic right inferior cerebellar infarct is also again seen.Again seen are foci of susceptibility effect adjacent to the central sulcus in the region of the chronic infarct and unchanged indicative of chronic blood products. Additional scattered foci of chronic microhemorrhages in the right frontal lobe and in the right parietal periatrial white matter also unchanged. No intracranial mass or mass-effect. No extra-axial collections. No hydrocephalus. There is interval development of diffuse opacification of the left mastoid air cells. Mucosal thickening involving the right maxillary sinus is again seen.Brain MRAAgain seen is left PCOM artery aneurysm measuring 3.2 mm at the neck and 6 mm in length. No evidence of interval enlargement allowing for differences in technique with prior MRA and CTA. The left posterior communicating artery arises in its medial and inferior aspect. Aneurysm projects posteriorly and inferiorly.There is bulbous appearance at the right superior cerebellar artery origin which is unchanged. There are atherosclerotic changes involving the cavernous and supraclinoid internal carotid arteries with ectasia of the anterior genu of the left cavernous carotid artery. The anterior communicating and bilateral posterior communicating arteries are patent. No additional aneurysmal dilatations or flow-limiting stenoses are evident in the anterior-posterior circulation.

Output: 1. Encephalomalacia involving the right frontal, temporal, and parietal lobes consistent with chronic right MCA territory infarct. No new infarcts. 2. Multiple foci of chronic microhemorrhage including within the area of prior infarct are unchanged.3. Allowing for differences in technique with prior CTA and 1.5T MRA from 6/2014, no significant change in left posterior communicating artery aneurysm measuring up to 6 mm in length and 3 mm at the base. Left PCOM artery arises from the medial and inferior aspect of the aneurysm.4. Interval development of opacification of the left mastoid air cells.