Unspecified abnormalities of gait and mobility [R26.9], Reason for Study: ^Reason: assess for cause of vertigo (posterior fossa lesion) History: gait impairment and vertigo No evidence of acute ischemic or hemorrhagic lesion.A small susceptibility lesion on the left periventricular white matter indicate either calcification or hemosiderin deposition. Since there is no associated surrounding edema, the lesion is likely to be chronic not acute.Multifocal scattered FLAIR high signal intensity lesions on periventricular white matter and centrum semiovale indicating nonspecific small vessel ischemic disease.The ventricles, sulci and cisterns are symmetric and unremarkable. There is no mass, mass effect, edema, midline shift, intra or extra-axial fluid collection/hemorrhage, or restricted diffusion/acute ischemia. The midline structures and cranial-cervical junction are normal. Normal flow voids are identified in the major intracranial vessels. The paranasal sinuses and mastoid air cells are clear.Cervical spine MRIThere is evidence of anterior fusion from the level of C3 to C4.The spinal cord at the level of C34 shows focal T2 high signal intensity indicating myelomalacia and severe spinal stenosis and bilateral severe neuroforaminal stenosis.C45 level also shows severe spinal stenosis with moderate to severe neuroforaminal stenosis.C56 level shows moderate right neuroforaminal stenosis, no evidence of spinal canal stenosis.C67 and C7T1 appear to be unremarkable.
1. No evidence of acute ischemic or hemorrhagic lesion.2. Non specific small vessel ischemic disease.3. Post anterior fusion status from C3 to C4 with focal myelomalacia at the level of C34 where severe spinal stenosis and severe bilateral neuroforaminal stenosis.4. Multilevel various degree degenerative changes of cervical spine as described above.