Multiple sclerosis: numbness, headaches. There are multiple, greater than 10, scattered cerebral white mater T2 hyperintense lesions bilaterally, predominantly in a periventricular distribution. Many of the lesions also display low T1 signal, but there is no abnormal intracranial enhancement. There is also a T2 hyperintense lesion in the right cerebellar hemisphere and within the spinal cord at the C3-4 level. The findings appear to be similar in extent as in 2015. There is no evidence of intracranial hemorrhage, mass, or acute infarct. The ventricles and basal cisterns are normal in size and configuration. There is no midline shift or herniation. The major cerebral flow voids are intact. The orbits, skull, and scalp soft tissues are grossly unremarkable. There is mild mucosal thickening in the bilateral maxillary sinuses.
Findings compatible with intracranial demyelinating lesions related to multiple sclerosis. A lesion in the cervical spinal cord also likely represents a demyelinating lesions related to multiple sclerosis. These findings are similar in extent as in 2015.