Diagnosis: Low back painClinical question: Vertebro-basilar insufficiency. Occipital neuralgia. Spinal stenosis in the cervical spine. MRI of the brainNo diffusion weighted abnormalities are appreciated.The CSF spaces are appropriate for the patient's stated age with no midline shift. Signal hyperintensity is present along the right anterior aspect of the medulla best identified on T2 imaging. This was also present on the previous exam.No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.Normal vascular flow voids are present in the distal carotid 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 left vertebral artery flow-void is present. The right vertebral artery is slightly smaller than the left vertebral artery but there is no flow void appreciated.The visualized portions of the paranasal sinuses demonstrate mucosal thickening. 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 a mild degree of periventricular and subcortical punctate hyperintense white matter lesions present identified on the FLAIR and T2 images.There is no evidence for intracranial aneurysm or cerebrovascular occlusion.The anterior communicating artery is identified and is medium size. There is fetal origin of the right posterior cerebral artery. The right P1 segment is medium-sized. The left posterior communicating artery is very small..No intracranial flow is identified in the right vertebral artery. There are tandem stenoses present along the basilar artery. One is located between the level of the anterior inferior cerebellar arteries and the superior cerebellar arteries and has approximately 80% stenosis which has not changed since the prior exam; it is located closer to the anterior inferior cerebellar arteries than the superior cerebellar arteries. On the 10/23/2012 exam this stenosis was not present. Another between the vertebrobasilar junction and the anterior inferior cerebellar arteries has 70% stenosis which has not changed significantly since the prior exam, however, it appears more stenotic than the 2012 exam.. No flow is identified in the distal intracranial right vertebral artery.MRA neck:There is opacification of the aortic arch, great vessels from the aortic arch and carotid arteries and left vertebral artery. There is no stenosis identified of the great vessels from the aortic arch. On the basis of NASCET criteria there is no significant stenosis at the carotid bifurcations. There is no significant stenosis along the course of the left vertebral artery. The right ascending cervical artery is fairly prominent. The right vertebral artery is occluded at its origin.Cervical spine:The cervical vertebral bodies are appropriate in overall alignment and height. There is ossification of the posterior longitudinal ligament present extending from the C2-3 level down to the C4-5 level associated with spinal stenosis. Spinal stenosis appears to be progressing gradually over time. When compared to the 2011 exam the spinal canal appears smaller on the current exam.At C2-3 there is no significant compromise to the spinal canal or neural foramina. There is narrowing of the right neural foramen. There is some narrowing of the AP dimension of the spinal canal due to ossification of the posterior longitudinal ligament at this level. These findings are stable compared to the prior exam.At C3-4 there is a ossification of posterior longitudinal ligament present this level associated with the effacement of spinal fluid ventral and posterior the spinal cord at this level and some mild flattening of the spinal cord. Effacement of the spinal fluid ventral and posterior to the spinal cord extends from the mid C3 vertebral level to the mid C4 vertebral level. There is encroachment of the exiting nerve roots bilaterally within the neural foramina at this level. These findings are stable compared to the prior exam.At C4-5 there is ossification of the posterior longitudinal ligament associated with a disc bulge and ligamentum flavum hypertrophy associated with effacement of spinal fluid ventral and posterior to the spinal cord. There is mild flattening of the spinal cord. Overall there is moderate spinal stenosis at this level. There is encroachment of the exiting nerve roots within the neural foramina. These findings are stable compared to the prior exam.At C5-6 there is no significant compromise to the spinal canal. There are some uncovertebral osteophytes present on the right-sided this level associated with disc material and mild narrowing of the right neural foramen. These findings are stable compared to the prior exam.At C6-7 there is no significant compromise to the spinal canal. There is narrowing of the neural foramina bilaterally at this level due to uncovertebral osteophytes and disc bulge. These findings are stable compared to the prior exam.At C7-T1 there is no significant compromise to the spinal canal or neural foramina.The left vertebral artery flow void is appreciated. The right vertebral artery has hyperintense signal within it on T2 imaging.
1.Tandem high-grade stenoses along the basilar artery. These are stable compared to the prior exam of 12/8/2014. Although not significantly different compared to last year's exam, compared to the 2012 exam, there appears to be progression of basilar artery stenoses.2.Occlusion of the right vertebral artery at its origin. No flow is appreciated in the right vertebral artery intracranially. 3.There is moderate spinal stenosis present in the upper cervical spine worse at the C3-4 and C4-5 levels related to ossification of the posterior longitudinal ligament and degenerative change. This is gradually progressed over the years. It is not significantly different than the 2014 exam, however, it appears to have progressed since 2011.4.There is encroachment of exiting nerve roots within the neural foramina of the cervical spine at C3-4 , C4-5 and C6-7.5.Periventricular and subcortical white matter changes of a mild degree are nonspecific. At this age they are most likely vascular related. 6.There is no evidence for acute cerebral infarction.7.Old lacunar infarction along the anterolateral aspect of the right medulla.