Clinical question: Evaluate occipital cyst, metastases? Signs and symptoms: Incontinence. Pre and post enhanced brain MRI:Diffusion weighted images are severely limited due to a large metallic artifact obscuring a significant portion of images on the left. Beyond the artifact there is no evidence of acute intracranial process and negative diffusion weighted series.There is also significant metallic caused artifact obscuring portion of the left orbit and left hemisphere. Beyond the artifact the anatomical morphology and signal intensity of brain remains within normal. Unremarkable cerebral cortex, cortical sulci, ventricular system, CSF spaces and the brain myelination.There is also no detectable abnormal enhancement of brain parenchyma or the leptomeninges beyond the metallic artifact.Within the limitation of the exam there is no detectable abnormal enhancement of the calvarium or the soft tissues of the scalp.Pre and post enhanced cervical MRI:Similar to prior exam from 8-1-15 there is mild degenerative changes of cervical spine and reversal of cervical lordosis.The signal intensity and the anatomical alignment of vertebral column however remains within normal and without abnormal enhancement.There is normal signal intensity and caliber of the cervical cord and without abnormal enhancement.No spinal stenosis or neural foraminal compromise at any level.Pre and post enhanced thoracic MRI:Similar to prior recent MRI of thoracic spine from 8-1-15 examination redemonstrates diffuse scattered small foci of T2 and T2 hyperintense and T1 hypointense throughout the vertebral column and with enhancement highly suggestive of metastatic disease. There is no evidence of fracture or malalignment and no detectable extraosseous spread of lesion into the epidural space or the paravertebral soft tissues. The lesions are detected in nearly all vertebral levels. The largest lesion is in the anterior body of T11 and measures approximately at 18 x 17 mm on sagittal T2 STIR series.The signal intensity and caliber of thoracic cord remains within normal and without abnormal enhancement. There is mild degenerative changes of thoracic spine however without evidence of spinal stenosis or neural foraminal compromise at any level.Unremarkable paraspinal soft tissues.Pre and post enhanced lumbosacral MRI:Examination demonstrates extensive recent postoperative changes of posterior laminectomy for debulking of tumor at L5-S3 levels. There is interval partial bulking of tumor within the sacral canal since prior exam. There is however no significant expansion of thecal sac which is mostly secondary to presence of extensive postoperative changes and to a smaller degree of residual tumor. Extensive postoperative changes on this initial postop study precludes precise assessment for degree of residual tumor and follow-up exam is recommended.Very large presacral residual tumor anterior and to the left at S1-S3 is again noted. Extensive loculated lymph nodes in the left prevertebral space is again identified without significant change. The nodes measured maximum of 35 mm in AP axis thickness and extent from approximately L1 through L5 levels. Revisualization of multiple small foci of marrow signal replacement and enhancement throughout the lumbar spine is again identified and concerning for metastatic disease. There is no detectable extension of disease process into the spinal canal from T2 through L5 levels which is a similar observation to prior exam.Severely distended bladder is again identified.
1.Pre- and post enhanced brain MRI is limited due to a large metallic artifact overlapping the left hemisphere. Beyond the region of artifact examination is unremarkable and in particular there is no evidence of metastatic disease.2.Pre and post enhanced MRI of cervical spine demonstrate mild degenerative disease and mild reversal of cervical lordosis. No abnormal enhancement of the vertebral column or the cord/leptomeninges. No central spinal stenosis or neural foraminal compromise.3.Pre- and post enhanced thoracic MRI demonstrate a small varying size foci of marrow signal replacement and enhancement involving nearly the entire vertebral column and highly suggestive of metastatic disease. Normal signal intensity and caliber of the cord without abnormal enhancement. No detectable extraosseous spread of lesions into the spinal canal, neural foraminal or paraspinal soft tissues. No spinal stenosis or neural foraminal compromise.4.Pre and post enhanced MRI of the lumbar spine demonstrate postoperative changes of posterior approach for debulking of tumor within the sacral canal. Extensive postoperative changes surgical level obscures the thecal sac and precludes precise assessment for detection of residual tumor within the canal. Follow-up is recommended after at least partial resolution of postop changes for better assessment. Beyond the region of surgery examination again demonstrate stable large presacral enhancing mass, extensive marrow signal replacement and enhancement of the sacral spine as well as multiple foci of marrow signal replacement and enhancement of L1 through L5 suggestive of metastatic disease. Extensive loculated prevertebral lymph nodes on the left extending from L1 through L5 without significant change since prior exam.