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MRA Circle of Willis and Head MRI Medical Transcription Sample

MRA SKULL BASE/CIRCLE OF WILLIS  

CLINICAL HISTORY:  The patient is a (XX)-year-old female with headaches.

FINDINGS:  Data acquisition was performed using time-of-flight technique with conventional angiographic type reconstructive images.

With respect to the posterior circulation, the upper portion of the vertebral arteries is not included in the field of view.  There is a normal appearance to the basilar artery without evidence of stenosis or aneurysm.  The left posterior cerebral artery has a normal origin off the basilar tip.  The right posterior cerebral artery has a normal developmental variant origin off the anterior circulation.

With respect to the anterior carotid circulation, there is a normal appearance of the petrous, cavernous and supraclinoid carotid vessels.  There is a normal appearance to the M1 and A1 segments without evidence of aneurysm or stenosis.  There is a normal complement of branches off the middle cerebral artery in the region of the articular cortex/sylvian fissure.  As was previously described, posterior cerebral artery appears to have its origin off the right internal carotid artery.  There may be a minute focal narrowing at the origin of the right posterior cerebral artery; the significance of this is uncertain, it may be artifactual.  The visualized portions of the right posterior cerebral artery show normal appearance in caliber.

IMPRESSION:  MR angiogram skull base/circle of Willis showing no evidence of aneurysm or vascular malformation.  Normal variant origin of the right posterior cerebral artery off the anterior circulation.  Tiny focal narrowing near the takeoff of the right posterior cerebral artery of questionable clinical significance; distal to this, the vessel has normal caliber.

Thank you for your kind referral.

HEAD MRI PRE AND POST CONTRAST

No prior studies available for comparisons.

CLINICAL HISTORY:  The patient is a (XX)-year-old female with headaches, possible trigeminal neuralgia.  Evaluate for tumor or MS.

TECHNIQUE:  Multiplanar images were obtained using multiple pulse sequences.  Post-gadolinium axial and coronal T1 weighted images were obtained.

FINDINGS:  Ventricular system overlying sulci are within normal limits.  T2 and inversion recovery images show no abnormal signal within the periventricular and deep white matter tracts to indicate a diffuse demyelinating process.  There is no intracranial mass, midline shift or extra-axial fluid collection.  Following administration of gadolinium, no abnormal areas of enhancement were seen.  Particular attention was directed to the region of Meckel cave and the fifth nerve complex.  There is no evidence of fifth nerve tumor or abnormal enhancement.  Incidental note is made of some minor inflammatory changes in the left maxillary sinus.

IMPRESSION:  Head MRI, essentially within normal limits.  Minor inflammatory changes within the left maxillary antrum.

Thank you for your kind referral.