Trauma to spine and ataxia. Fall at home few days prior to presentation. Brain: There is no evidence of acute intracranial hemorrhage, mass, or acute infarct. There is mild nonspecific cerebral and pontine white matter T2 hyperintensity. There is also a small focus of encephalomalacia in the left thalamus. However, the cerebellum appears to be unremarkable. There is a punctate focus of susceptibility effect in the right thalamus, which may represent a chronic microhemorrhage. The ventricles and basal cisterns are normal in size and configuration. However, there are mild bilateral cerebral convexity subdural fluid collections, measuring up to 5 mm in thickness. There is no midline shift or herniation. The major cerebral flow voids are intact. The orbits, skull, paranasal sinuses, and scalp soft tissues are grossly unremarkable.Cervical Spine: There is intermediate to high T1 and low T2 signal material in the anterior epidural space of the cervical spinal canal at the C1-4 levels, measuring up to approximately 5 mm in thickness, with associated narrowing of the thecal sac. However, the spinal cord signal is normal. There is high T2 signal in the interspinous spaces at Oc-C1 and C1-2 levels. There is degenerative vertebral bone marrow signal alteration in the cervical spine, particularly at C6-7. There are small effusions in the bilateral C5-6 facet joints. There is 3 mm of anterolisthesis of C4 on C5. There is also slight retrolisthesis of C3 on C4. There are multilevel degenerative changes of the cervical spine with multilevel neural foraminal stenosis of varying degrees.
1. Chronic lacunar infarct in the left thalamus, but no evidence of acute infarct.2. Mild bilateral cerebral convexity subdural fluid collection may represent hygromas. 3. Findings suggestive of early subacute hemorrhage within the anterior spinal canal at the C1-4 levels with associated narrowing of the thecal sac. However, the spinal cord signal is normal.4. Findings suggestive of soft tissue strain and perhaps ligamentous injury in the interspinous spaces at Oc-C1 and C1-2 levels.Discussed with Dr. DEL BRUTTO ANDRADE at 11 AM on 3/13/16.