Elevated protein in CSF, evaluate for encephalitis versus infectious process. Patient has also history recent fall and now weakness. Evaluate for cervical cord lesion. Brain:There are foci of mildly restricted diffusion involving the right and left frontal lobe as well as the right occipital lobe. ADC values are isointense and favored to represent subacute infarcts.There are bilateral subdural collections which are predominately CSF intensity with areas susceptibility noted within the right frontal region. Collection measures up to 11 mm on the right and 9 mm on the left. There is mild associated mass effect. There is a subacute component in the bilateral frontal region with mild T1 hypointensity and T2 hypointensity. Tiny T1 hyperintense component is noted in the anterior left frontal lobe along the cortical surface which may represent a tiny cortical contusion. No significant change since CT dated 2/8/2015. There is global parenchymal volume loss, commensurate with patient's advanced age.Several foci of T2/FLAIR hyperintensity are seen in the bilateral subcortical and periventricular white matter, which are nonspecific, but compatible with mild chronic small vessel ischemic changes. No abnormal parenchymal or leptomeningeal enhancement. Minimal dural enhancement is seen. Major flow-voids are preserved.There is diffuse opacification of the bilateral mastoid air cells, which may related to intubation. There is moderate opacification throughout the paranasal sinuses, worst involving the left maxillary sinusCervical Spine:Craniovertebral junction appears within normal limits. The cervical vertebral bodies are appropriate height. There is mild retrolisthesis of C5 on C6 retrolisthesis and minimal retrolisthesis of C6 on C7. Bone marrow signal is within normal limits. Artifact somewhat limits evaluation for cord signal abnormality however no definite cord signal abnormality is seen.Degenerative changes are seen in the cervical spine as described below:C2-3: No significant compromise to the spinal canal or neural foramina. Ligamentum flavum thickening noted dorsally.C3-4: No significant compromise to the spinal canal or neural foramina.C4-5: No significant compromise to the spinal canal or neural foramina.C5-6: There is disk osteophyte complex with effacement of the ventral thecal sac. Dorsal thecal sac is preserved. There is moderate left and mild right neural foramina narrowing.C6-7: There is disk osteophyte complex with effacement of the ventral thecal sac. Dorsal thecal sac preserved. There is moderate left and mild right neural foramina narrowing.C7-T1: No significant compromise to the spinal canal or neural foramina.Mild facet arthropathy is also seen in the cervical spine. There is mild edema involving the dorsal paraspinous soft tissues from C2 to C5. The anterior and posterior longitudinal ligaments are intact. Ligamentum flavum is also intact.
1. Tiny foci of mildly restricted diffusion involving the bilateral frontal and right occipital lobes likely representing tiny subacute infarcts. In the setting of infection, septic emboli may be considered.2. Bilateral subdural collections with signal features compatible with subacute on chronic subdural hematomas with mild local mass effect. Subacute subdural component is seen along the anterior frontal convexities. Tiny focus of hemorrhage along the cortical surface of the anterior left superior frontal gyrus may represent a contusion.3. No evidence of intraparenchymal abscess or empyema. No abnormal parenchymal or leptomeningeal enhancement is seen to suggest infection however CSF would be more sensitive if there is suspicion for meningitis. Minimal pachymeningeal enhancement is seen which may be reactive and related to the subdural collections.4. Artifact slightly limits evaluation for cord signal abnormality however no definite cord signal abnormality is appreciated. No evidence of intraspinal hematoma. 5. Degenerative changes in the cervical spine without evidence of high-grade spinal canal stenosis at any level. Mild to moderate neural foraminal narrowing at multiple levels as detailed above.6. Edema involving the posterior paraspinous soft tissues from C2 to C5 is nonspecific but given history of trauma, may suggest mild ligamentous injury involving the interspinous ligaments. The anterior and posterior longitudinal ligaments as well as ligamentum flavum are intact. Please note CT of the cervical spine is more sensitive for subtle fractures and can be considered if clinically warranted.Dr. Ali discussed findings with Dr. Cueva (neurology) at 1215 hrs on 2/10/2015.