57 years Female (DOB:10/4/1959)Reason: h/o Chiari s/p decompression with nystagmus HA and ataxia History: h/o Chiari s/p decompression with nystagmus HA and ataxiaPROVIDER/ATTENDING NAME: CHRISTOPHER M GOMEZ CHRISTOPHER M GOMEZ The CSF spaces are appropriate for the patient's stated age with no midline shift. The patient status post suboccipital craniotomy. There is reversal of normal cervical curvature present. There is no evidence for ventriculomegaly or syrinx.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.CSF flow study is stable.The visualized portions of the paranasal sinuses demonstrate a small mucous retention cyst in the right maxillary sinus.. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact.
Status post suboccipital craniotomy for Chiari I malformation. There is no evidence for ventriculomegaly on this exam and no significant change compared to the prior exam.