Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

BRAIN MRI WITH AND WITHOUT GADOLINIUM AND INTERNAL AUDITORY CANAL STUDY TRANSCRIBED SAMPLE

Images through the head were taken both with and without contrast in the normal fashion.  No evidence of abnormal enhancement is seen on the thin section coronal and axial images through the internal auditory canal or cerebellopontine angle regions.  The cerebral and cerebellar hemispheres also reveal no focal abnormal enhancement to suggest a mass in any of these areas.  The venous drainage pattern does suggest a slight irregularity in the left sigmoid sinus, in the posterior fossa.  It was persistent on several images.  It is unclear whether this could represent some mixed drainage flow or perhaps a very small thrombus.  If this would correspond to any symptoms of the patient, one may want to proceed to an MRV.  FLAIR images do not show evidence of white matter lesions to indicate demyelination and ischemic or other disease.  Development of gray and white matter is within normal limits.  No sellar or parasellar changes are indicated.  The brain stem is intact.  No significant sinus disease is indicated.  This includes the mastoid air cell sinuses as well.

IMPRESSION:
1.  No internal auditory canal acoustic neuroma or other tumors are indicated in the cerebellopontine angle of internal auditory canal region.  No abnormal enhancement throughout the study and no abnormalities to gray or white matter is seen.
2.  Slight irregularity noted in the left sigmoid sinus may be due to different venous drainage patterns or perhaps indicate a very small thrombus in that region.  If this would correlate to the patient’s symptoms, then MRV may be helpful.

Medical Transcription Word Seeker - Google Custom Search for MTs - Searches just Medical Websites