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Brain MRI With and Without Contrast Transcription Sample Report

BRAIN MRI WITH AND WITHOUT CONTRAST

MRI is performed both with and without contrast using thin sections to the pituitary and sellar regions.  Postcontrast whole-head images were also performed.  We see on the noncontrast images, through the pituitary, a slightly irregular and/or more prominent posterior pituitary area of high signal.  Because of the substance difference present in the anterior pituitary versus the posterior pituitary, it is common to see a change in intensity on MRI between these two areas of the pituitary gland.  The posterior pituitary region of high signal is usually slightly more concave whereupon it appears somewhat dumbbell shaped on today's exam.  The amount of high signal is not significant enough to suggest a focal hemorrhage or definite other mass.  However, when contrast was given, in the immediate post-sagittal images, we did see on one image only a small area of inhomogeneous enhancement directly at the more anterior component of this area of high signal, presumed to be part of the posterior pituitary gland.  This is midline and directly beneath the pituitary stalk.  Although it is felt that this may be related to a slightly more prominent pituitary gland than normal, the possibility of a slightly unusual presenting pituitary adenoma must be considered.  This did show homogeneous enhancement on the coronal images, which were taken after the immediate bolus images in the sagittal plane.  The pituitary gland is normal in size overall.  The pituitary stalk is midline.  The optic chiasm is not compressed or affected in any manner.  The parasellar regions including the carotid artery areas are unremarkable.  I see no parasellar meningioma or other mass.  Images of the whole head both using T2 weighted imaging and contrast-enhanced T1 weighted imaging show no areas of other abnormality in the cerebral or cerebellar hemisphere regions.  We do see that the posterior and inferior component of the sphenoid sinus slightly left of midline does contain a small focus of probable mucus retention cyst or mucosal redundancy.

IMPRESSION:  
1.  The posterior pituitary gland is somewhat more prominent than often seen.  It is apparent because of its slightly higher intensity signal than the anterior pituitary gland, which is normal.  However, on the immediate postcontrast images, the most anterior component of this area of high signal, which resides directly below the pituitary stalk midline and posterior, do not show uniform enhancement.  This could be a normal variant.  It could, however, represent a very small adenoma presenting with a slump, somewhat unusual noncontrast high signal equal to the pituitary gland.  This area measures only about 3-4 mm.  The rest of the gland enhances homogeneously both on the immediate and delayed images.
2.  The pituitary gland is of normal size and shape overall and the pituitary stalk and optic chiasm are all felt to be unremarkable, as are the remaining parasellar structures.
3.  Small focus of probable mucosal disease in the posterior left sphenoid sinus.

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MRA OF THE BRAIN

We do not see evidence, on this routine time-of-flight MRA, of any aneurysmal dilatation of the basilar artery or basilar tip aneurysm.  Basilar artery is intact.  There is one dominant feeding vertebral artery, which is not an unusual presentation.  Each of the internal carotid arteries show a very small amount of plaque disease.  The middle cerebral arteries are symmetrical and show some small tapering of the distal ends, which may indicate some mild atherosclerotic disease as well.  There is no aneurysmal dilatation or berry aneurysms in the normal location of the anterior communicating artery or the MCA/ICA bifurcation points.  Today's examination does not show definite posterior communicating artery.  There is a slim chance on today's examination that there may be a very small flow within a possible remnant posterior communicating artery on the left.

IMPRESSION:  Mild atherosclerotic disease.  No evidence of an aneurysm of the basilar artery or elsewhere is seen on the examination.

MRI OF THE BRAIN WITH CONTRAST:

This is a followup for the noncontrast MRI recently performed.  Today's examination does not show the small density seen anterior to the medulla, at the medulla-pons junction, to enhance.  When comparing it to the FLAIR images taken prior, we again see a very subtle presence in the area on the T1 weighted images today, with contrast, of some vague density in the same area, which brightly intensified on FLAIR imaging on the prior examination.  It also was well seen on the fast spin echo T2 on the prior examination.  As this area does not enhance, one might include a colloid cyst.  On further examination of the prior study, there is a small oval-shaped area of high signal also noted in the third ventricle.  This is sometimes a location for colloid cyst obstruction.  The ventricular system does not appear hydrocephalic at this time nor is there evidence of definite transependymal flow secondary to increased CSF pressure.  Neither of the very small change in the third ventricle nor that anterior to the brainstem enhances nor has it changed on today's examination when compared to prior study.  The remaining portion of the head also showed no abnormal enhancement with gadolinium.

IMPRESSION:  
1.  No abnormal enhancement of the mass of concern or elsewhere in this examination with gadolinium.
2.  The small focus anterior to the brainstem seen on the prior examination does again appear present on the sagittal images today suggesting that it is less likely an artifact.
3.  The small approximately 7 mm density presents as high signal on FLAIR and T2 weighted images on prior study, and in retrospect, there is a second small oval-shaped density in the third ventricle.  This is less than 1 cm.  These two densities may represent colloid cyst or an unusual artifact from draining veins.  I see no evidence of hydrocephalus to suggest that this is a definite obstructing cyst in the third ventricle.  In light of the negative MRA and no gadolinium uptake, one course of action would be to follow these carefully and see if there is any change in the ventricular size to indicate an obstructing process and any change in the brainstem to suggest a compressive process to the initially seen 7 mm density on the prior study.  If these are two colloid cysts, close followup is advised.  The alternative of abnormal enhancement due to an artifact of vascular flow, perhaps draining veins, is a possibility but felt less likely.  Should symptoms remain stable, one may want to repeat this examination in 6 months to make certain these two densities also remain stable.

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