Diagnosis: Headache(784.0)Other diseases of lung, not elsewhere classifiedClinical question: Inflammatory pseudotumor, f/u progressionSigns and Symptoms: headaches The CSF spaces are appropriate for the patient's stated age with no midline shift. No abnormal enhancing mass lesions are appreciated intracranially. No intracranial hemorrhage is identified. No edema is identified within the brain parenchyma.The patient is status post left parietal craniotomy. There is adjacent dural enhancement which is unchanged from the prior exam.There is a focus of encephalomalacia present along the posterior aspect of the left paracentral lobule and the anterior aspect of the left precuneus. This has not changed since the prior examThe cerebellar tonsils are low lying extending 3 mm below the level of the foramen magnum.Normal vascular flow voids are present in the distal carotid and vertebral 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 visualized portions of the paranasal sinuses demonstrate mild mucosal thickening along the left maxillary sinus. The visualized portions of the mastoid air cells redemonstrate partial opacification of the right mastoid air cells and middle ear. The patient is status post right mastoid surgery. The visualized portions of the orbits are intact.
1.The patient is status post left parietal craniotomy. There is encephalomalacia present in the left medial parietal lobe associated with adjacent dural thickening all of which is stable and compared to the prior exam. The patient has a prior diagnosis of dural pseudotumor.2.Opacification of the right mastoid air cells and middle ears persists and is associated with contrast enhancement is a stable compared to the prior exam. The patient is status post right mastoid surgery. Please correlate with surgical findings.3.Low-lying cerebellar tonsils.