Spina bifida with hydrocephalus, unspecified region [741.00], Reason for Study: ^Reason: eval for pathology s/p Chiari decompression History: LUE weakness and paresthesias Post suboccipital craniectomy status for the decompression of Chiari malformation. There is focal hemorrhage on the left posterior aspect of the lower medulla which extends to cervical medullary junction caudally and to the level of left inferior cerebellar peduncle cranial with surrounding edema.There is MR evidence of sub-occipital area dural irregularity and susceptibility artifacts indicating post surgical status.Multiple round susceptibility artifacts on anterior aspects of bilateral frontal lobes indicate postoperative pneumocephalus.There is no evidence of acute ischemic lesion on the scan.The ventricles, sulci and cisterns are symmetric and unremarkable. Normal flow voids are identified in the major intracranial vessels. The paranasal sinuses and mastoid air cells are clear.
1. Post decompressive suboccipital craniectomy status.2. Acute hemorrhage on the left posterior aspect of the lower medulla as described above with surrounding edema.3. No acute ischemic lesion.