18 years Female (DOB:8/22/1997)Reason: Please evaluate for acute transverse myelitis History: weaknessPROVIDER/ATTENDING NAME: EBELE N CHINWUBA ENZO J GARCIA MRI brain:The CSF spaces are appropriate for the patient's stated age with no midline shift. There is a T2 signal hyperintense lesion present in the right paramedian genu of the corpus callosum measuring 8 x 11 mm axial dimensions. This was not present on the 4/8/2016 exam. It is not associated with diffusion restriction.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.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.MRI cervical spine:The cervical vertebral bodies are appropriate in overall alignment and height. This cervical spinal cord is enlarged with a posterior and centrally centered signal hyperintensity from the level of the medulla inferiorly into the thoracic cord down to the T3 level. This appears to be slightly more extensive on the current versus the prior exam.At C2-3 there is no significant compromise to the spinal canal or neural foramina.At C3-4 there is no significant compromise to the spinal canal or neural foramina.At C4-5 there is no significant compromise to the spinal canal or neural foramina.At C5-6 there is no significant compromise to the spinal canal or neural foramina.At C6-7 there is no significant compromise to the spinal canal or neural foramina.At C7-T1 there is no significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact.Thoracic spine:The thoracic vertebral bodies are appropriate in the overall alignment and height. There is no compromise of thoracic spinal canal or exiting nerve roots. There is extension of signal hyperintensity within the central portion of the spinal cord from the visualized cervical cord down to the T3 level. There is more subtle cord enlargement and a 5 x 2 mm sagittal dimension signal hyperintensity at the T11 level along the posterior aspect of the spinal cord. Another smaller T2 hyperintense lesions present within the posterior aspect of the thoracic spinal cord at the T10 level measuring 4 mm x 1 mm sagittal dimensions.Lumbar spine:Five lumbar type vertebral bodies are presumed to be present which are appropriate in overall alignment and height. The conus medullaris on sagittal imaging is grossly intact. At L5-S1 there is no significant compromise to spinal canal or neural foramina.At L4-5 there is no significant compromise to spinal canal or neural foramina.At L3-4 there is no significant compromise to spinal canal or neural foramina.At L2-3 there is no significant compromise to spinal canal or neural foramina.At L1-2 there is no significant compromise to spinal canal or neural foramina.There is fluid within the uterus.
1.There is abnormal signal and enlargement of the cervical spinal cord which is suspected represent an inflammatory myelitis. This has mildly progressed when compared to the prior exam.2.A couple small lesions are present in the distal thoracic spinal cord. These are nonspecific and unchanged since the prior exam. One possibility is that these are foci of demyelination given the patient's clinical history.3.There is a new lesion present within the genu of the corpus callosum. This is nonspecific but could represent a focus of demyelination given the patient's clinical history.