Unspecified abnormalities of gait and mobility [R26.9], Reason for Study: ^Reason: Gait disturbance hyper reflexia History: above 85 years Male (DOB:9/6/1931)Reason: Gait disturbance hyper reflexia History: abovePROVIDER/ATTENDING NAME: THOMAS J. KELLY THOMAS J. KELLY Brain MRINo evidence of acute ischemic or hemorrhagic lesion.Multifocal scattered FLAIR/T2 high signal intensity lesions are seen on bilateral periventricular white matter and centrum semiovale indicating nonspecific small vessel ischemic disease.There are scattered lacunar infarcts involving bilateral basal ganglia, bilateral caudate heads and the left cerebellar hemisphere. The CSF spaces are appropriate for the patient's stated age with no midline shift. 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 major intracranial arterial system.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.Bilateral lenses are not seen indicating postoperative status.Cervical MRIThere is normal cervical lordosis. The cranial-cervical junction is normal. Spinal cord signal intensity is normal.Degenerative changes are as follows; C23: Within normal limits.C34: Diffuse bulging of osteophyte disc complex with bilateral ligamentum flavum thickening results mild spinal canal and bilateral neuroforaminal stenosis.C45: Minimal focal bulging of disc, otherwise unremarkable.C56: Central to right osteophyte disc complex bulging which abuts thecal sac with bilateral ligamentum flavum thickening results mild to moderate spinal canal stenosis. Minimal to mild right lateral recess stenosis at this level is also seen. C67: Minimal bulging of disc, otherwise unremarkable.
1. No evidence of acute ischemic or hemorrhagic lesion.2. Nonspecific small vessel ischemic disease.3. Multiple lacunar infarcts in bilateral basal ganglia, caudate heads and left cerebellar hemisphere. 4. Degenerative spondylosis of cervical spine with C34 and C56 spinal canal stenosis. 5. Normal cervical spina cord signal intensity.