59-year-old male to evaluate for stroke. Additionally obtained clinical history indicates left-sided numbness. There is no evidence of intracranial hemorrhage, mass or edema. There is no definite evidence of cortical stroke. The ventricles are midline, with normal volume and morphology. There is minimal crowding of the foramen magnum, raising the possibility of tonsillar ectopia/herniation. This may be further evaluated by MRI if clinically indicated.The calvaria and skull base are radiographically normal. The visualized paranasal sinuses and mastoid air cells are normally pneumatized.
1. No evidence of acute intracranial hemorrhage or cortical stroke.2. Possible mild crowding of the foramen magnum, raising the possibility of tonsillar ectopia/herniation. This may be further evaluated by MRI if clinically indicated.Findings were discussed with Dr. M. Sih at the time of dictation.