52-year-old female with worsening headaches. Evaluate for progression; Chiari. The patient also has sciatic nerve pain. Evaluate for stenosis.Additional EMR Data: History of Chiari malformation, HTN, impaired glucose tolerance, HLD, and ?h/o MS (off of Betaseron since 2006 given nonspecific MRI sxs, not clear diagnosis) who presents for f/u. Brain MRI:Limited exam secondary to patient motion. Nonspecific hyperintense FLAIR foci are again seen predominantly in the subcortical white matter of the bilateral cerebral hemispheres and there are at least a few more foci compared to the previous exam predominantly in the frontal lobes within the subcortical white matter.On the current exam there is moderate crowding of the foramen magnum and the cerebellar tonsils extend at most 4 mm below the foramen magnum which is at the upper limits of normal. In addition the cerebellar tonsils have a more rounded configuration compared to the previous exam and this is suspected to be in part related to changes in head position compared to the previous exam, as there is decreased extension of the neck. There is relatively decreased CSF flow posteriorly at the level of the foramen magnum just distal to the caudal tip of the tonsils but there is biphasic flow detected through the cerebral aqueduct, fourth ventricle and outflow tracts.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, paranasal sinuses, and scalp soft tissues are grossly unremarkable.L-spine MRI:There is transitional lumbosacral anatomy with sacralization of the L5 vertebral body, four non-rib bearing lumbar vertebral bodies and twelve rib-bearing vertebrae. For the purposes of this exam, the last fully formed disc is at L4-5 with a rudimentary disc at the L5-S1 level.There is slightly exaggerated lordosis of the lumbar spine and stable grade 1 degenerative anterolisthesis of L4 on L5. There is also disk narrowing and dessication at L4-5. There is also a developmentally narrowed lower lumbar spinal canal due to short pedicles and prominent dorsal epidural fat. The vertebral body heights are preserved. The marrow is heterogeneous, although unchanged compared to the prior exam. The conus is normal in signal and morphology and terminates at the mid-L2 level.Again seen is uncovering of the L4-5 disc with a superimposed mild disc bulge and moderate to severe facet arthropathy which contribute to mild-moderate right and moderate-severe left neuroforaminal narrowing and at least moderate spinal canal stenosis but this is not significantly changed.Small right mid-kidney cyst is again noted. The paravertebral soft tissues are unremarkable.
1.Slight interval progression of the predominantly subcortical FLAIR hyperintense foci which remain nonspecific.2.Persistent moderate crowding of the foramen magnum with now normal cerebellar tonsil morphology and positioning, likely in part related to change in the patient's head position. Current imaging does not meet the criteria for Chiari malformation. Biphasic flow of CSF through this level, although there is relatively decreased flow dorsally just caudal to the tonsils. Correlate clinically.3.Transitional lumbosacral anatomy as noted above. If surgery is to be contemplated, recommend correlation with imaging of the entire spine. 4.Unchanged appearance of the focal degenerative disease at the L4-5 level with moderate-severe left neuroforaminal narrowing and moderate spinal canal stenosis at this level, with underlying developmental narrowing of the canal.