Diagnosis: Encounter for examination for normal comparison and control in clinical research programClinical question: Day 28: clinical trial eval The patient status post right frontal craniotomy for removal of a right frontal lobe mass. There is signal hyperintensity present along the right frontal lobe within the subcortical and periventricular white matter in the right superior middle and inferior frontal gyri as well as the white matter of the right external capsule. The extent of the white matter signal abnormality remains stable and compared to the previous exam from October 19, however, this white matter signal change appears to be more extensive than on the 7/23/2015 exam. Compared to the 9/15/2015 exam - which is preoperative- the outer extent of the white matter signal change appears very similar. There are punctate foci of susceptibility effect present within the white matter signal change adjacent to the surgical site. These were also present on the 9/15/2015 exam. There is redemonstration of ill-defined patchy enhancement where these punctate foci of susceptibility are surrounding the surgical margins . This contrast enhancement is stable and compared to the previous exam.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 are clear. The visualized portions of the mastoid air cells are clear. The visualized portions of the orbits are intact.
Since the previous exam is no substantial change. There is redemonstration of status post right frontal lobe surgery. The possibility of a residual neoplasm in the remaining right frontal lobe cannot be excluded.