History of traumatic brain injury with intracranial hemorrhage at age 4 presenting with abnormal gait and tremor. Evaluate for brain lesions or atrophy. Brain: There is no evidence of intracranial hemorrhage, mass, or acute infarct. There is thinning of the posterior body of the corpus callosum with relative sparing of the splenium. There are scattered punctate foci of abnormal T2/FLAIR hyperintensity within the periventricular and subcortical white matter as well as T2 hyperintense signal along the periatrial white matter. The ventricles and basal cisterns are normal in size and configuration. There is no midline shift or herniation. The skull and extracranial soft tissues are unremarkable. Cervical spine: The vertebral column alignment is within normal limits. The vertebral body and disc space heights are preserved. The vertebral bone marrow signal is unremarkable. There are minimal disc bulges throughout the cervical spine with no significant spinal canal or neural foraminal stenosis. The spinal cord displays normal signal and morphology. The paravertebral soft tissues are unremarkable.
1. Constellation of findings including thinning of the posterior body of the corpus callosum and signal abnormality of the periatrial white matter along the callosal fibers as well as scattered punctate lesions in the white matter throughout the cerebral hemispheres, could reflect sequela of prior chronic traumatic injury. Additional differential considerations include demyelinating, post inflammatory or vasculitic process among others.2. No significant spinal canal or neural foraminal stenosis of the cervical spine.