Patient with history of schizophrenia; 4 day hx of "comatose state" without recovery back to baseline and subsequent cognitive impairment+parkinsonism and impaired vertical gaze; subacute onset; look for cortical ribboning, midbrain atrophy. Symmetrical hyperreflexia. Brain: There appears to be mild disproportionate volume loss involving the midbrain, better appreciated on the post gadolinium T1 sequence with thinner slices. There also appears to be mild concavity of the lateral midbrain tegmentum. Pontine and cerebellar volumes are maintained without signal abnormality. No appreciable abnormal mineralization involving the basal ganglia or midbrain. 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. These are relatively more conspicuous in the left corona radiata. There is suggestion of small chronic lacunar infarcts involving the bilateral thalami. There is a punctate focus of susceptibility involving the right frontal subcortical white matter consistent with chronic microhemorrhage. No restricted diffusion to suggest acute ischemia. No intracranial mass or mass-effect. The ventricles are within normal limits in size and configuration. No abnormal parenchymal or meningeal enhancement. Major flow-voids are preserved.Sella and orbits are grossly within normal limits. There is diffuse opacification of the bilateral mastoid air cells. Minimal scattered opacification of the paranasal sinuses. Bone marrow signal and extracranial soft tissues are within normal limits. Cervical spine: Craniovertebral junction appears within normal limits. The cervical vertebral bodies are appropriate in height. Alignment is maintained. Bone marrow signal is within normal limits. The cervical spinal cord has normal signal characteristics and overall morphology.Degenerative changes are seen in the cervical spine as described below:C2-3: No significant compromise to the spinal canal or neural foramina.C3-4: Small disc osteophyte complex with effacement of the ventral thecal sac and overall mild narrowing of the spinal canal. Minimal narrowing of the neural foramina. C4-5: Disc osteophyte complex which effaces the ventral thecal sac and mildly indents the ventral cord. Overall mild spinal canal stenosis. There is mild to moderate right and mild left neural foraminal stenosis.C5-6: No significant compromise to the spinal canal or left neural foramen. Minimal right neural foraminal narrowing related to uncovertebral hypertrophy.C6-7: Minimal disc osteophyte complex. No significant compromise to the spinal canal or neural foramina.C7-T1: No significant compromise to the spinal canal or neural foramina.The vertebral artery flow voids appear to be intact. Paraspinous soft tissue structures appear within normal limits.
1. There appears to be mild disproportionate volume loss involving the midbrain which may represent progressive supranuclear palsy in the appropriate clinical setting.2. Mild chronic small vessel ischemic disease. Foci of volume loss involving the bilateral thalami compatible with lacunar infarcts related to prior ischemia or other injury.3. Mild degenerative changes in the cervical spine, relatively worse at the C4-C5 level, but without high-grade spinal canal stenosis or cord signal abnormality at any level. Additional details as above.4. Opacification of the bilateral mastoid air cells which is nonspecific.