65 years Female (DOB:6/8/1951)Reason: CSF leak with ventriculomegaly from pneumocephalus History: AMS, CSF leak, pneumocephalusPROVIDER/ATTENDING NAME: AGNIESZKA ANNA ARDELT AGNIESZKA ANNA ARDELT MRI of the brainThere is intracranial air present within the lateral ventricles as well as just anterior to the right temporal lobe. Interval extends into the right sphenoid sinus. There is a defect present along the lateral aspect of the right sphenoid sinus.There is a focus of encephalomalacia present along the right frontal lobe anteriorly which was also present on the prior exam.There is a 12 mm extra-axial mass adjacent to the left cerebellar hemisphere and of the left tentorial leaf as well as the left occipital bone. It is unchanged since prior exam.There are several periventricular and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images. 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.MRA brain:Antegrade flow is present in the distal internal carotid arteries, the distal vertebral arteries, the basilar artery and the proximal anterior, middle and posterior cerebral arteries.There is no evidence for intracranial aneurysm or cerebrovascular occlusion.The anterior communicating artery is identified. The posterior communicating arteries are not readily identified. The vertebral arteries are similar in size.
1.There is a defect present along the lateral wall of the right sphenoid sinus which appears to represent a source for potential CSF leak. There is associated intracranial air (pneumocephalus) present.2.There is redemonstration of a small extra-axial lesion adjacent to the left cerebellar hemisphere which is stable since 2007.3.No evidence for intracranial aneurysm.4.No evidence for intracranial cerebrovascular occlusive disease5.Several Periventricular and subcortical white matter lesions are present which are nonspecific. At this age they are most likely vascular related. 