34 years Female (DOB:4/27/1982)Reason: hx L sphenoid dehiscence w CSF leak History: hx L sphenoid dehiscence w CSF leakPROVIDER/ATTENDING NAME: JAYANT M PINTO JAYANT M PINTO There is a T2 hyperintense lesion present adjacent to the left middle cranial fossa and anterior to it but behind the pterygopalatine fossa. It measures approximately 23 x 19 mm coronal dimensions and 23 x 14 mm axial dimensions. It appears to communicate with the left middle cranial fossa. This communication is better depicted on the recent CT of the paranasal sinuses. It bulges into the left sphenoid sinus. There is communication with the left sylvian fissure. Soft tissue within the encephalocele extends from the left temporal lobe through the defect.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 demonstrate mucous retention cysts in the maxillary sinuses as well as the bulging lesion from the left middle cranial fossa. There is an air-fluid level in the sphenoid sinus.. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact.
1.Findings are suspicious for an encephalocele extending from the left middle cranial fossa into the infratemporal fossa just behind the pterygopalatine fossa. It bulges into the left sphenoid sinus where there is an air-fluid level raising the question of CSF leak. Please refer to CT of the paranasal sinuses for further comments.